Vertebral Anomalies in Microtia Patients at a Tertiary Pediatric Care Center.

OBJECTIVE: Microtia is a congenital condition known to be associated with vertebral anomalies and congenital syndromes, most prominently hemifacial microsomia. There is controversy, however, on whether to screen with spinal imaging. Additionally, microtia ear reconstruction utilizes rib harvesting that could potentially worsen pre-existing vertebral and rib anomalies, specifically scoliosis. We report on the prevalence and characteristics of vertebral anomalies among microtia patients at a tertiary pediatric center. STUDY DESIGN: Retrospective case review with literature review. SETTING: Tertiary pediatric referral center. METHODS: A review of 425 children with microtia was conducted, characterized as either syndromic or nonsyndromic. Data included demographics, spinal imaging performed, indications, anomalies detected, and microtia repair. RESULTS: Among 425 microtia patients, 24.5% were syndromic with an average age of 9.7 years. Only 18.4% of all patients had spinal imaging performed (50% syndromic vs 8.1% nonsyndromic). Overall, 10.6% had a vertebral anomaly with a 57.7% detection rate (67.3% syndromic vs 38.5% nonsyndromic). The most common anomaly was scoliosis, with a prevalence of 7.8%. Fusion defects and rib deformities were the next most prominent. Microtia repair, most commonly with an autologous rib graft, was performed in 21.6% of the cohort. However, only 19.2% had spinal imaging and 16.7% with a vertebral anomaly. CONCLUSION: Children with microtia are at a greater risk of vertebral abnormalities. Scoliosis prevalence in isolated microtia is comparable to the general population (2%-3%) but greatly increased with genetic syndromes. Screening for vertebral anomalies should be considered when planning microtia reconstructions, especially in the syndromic population.

Reduction in school individualized education program (IEP) services during the COVID-19 pandemic.

Purpose: The COVID-19 pandemic created novel challenges for school systems and students, particularly students with disabilities. In the shift to remote/distance learning, this report explores the degree to which children with disabilities did not receive the special education and related services defined in their individualized education program (IEP). Methods: Patients attending an outpatient tertiary care center for neurodevelopmental disabilities in Maryland were surveyed on the impact of the pandemic on educational services provision. Results: Nearly half (46%) of respondents qualified for special education and related services through an IEP before the start of the COVID-19 pandemic. Among those with IEPs, 48% attested to reduced frequency and/or duration of special education and/or related services during the pandemic. The reduction was greatest in occupational therapy services (47%), followed physical therapy services (46%), and special education services (34%). Conclusion: This survey of children with disabilities observes a substantial reduction in IEP services reported in their completed surveys. To address the observed reduction in IEP services, we sought additional education for clinicians on the rights of students with disabilities in anticipation of students' re-entry to the classroom. A special education law attorney provided an instructional session on compensatory education and recovery services to prepare clinicians to properly inform parents about their rights and advocate for patients with unmet IEP services during the pandemic.

The Mydriatic Red Eye as the Initial Presentation of Syphilis.

BACKGROUND: Syphilis is a sexually transmitted infection that has been increasing in prevalence since the early 2000s. Ocular involvement occurs in a minority of patients and must be in the differential diagnosis for patients who present with red eye and uveitis. CASE REPORT: A 29-year-old woman presented to the emergency department with a painful, mydriatic red eye. Review of systems revealed a rash as well as a recent genital lesion and, on further questioning, she admitted to a history of intravenous drug use and high-risk sexual activity. Ophthalmology was consulted and the patient was diagnosed with bilateral uveitis. Serologic testing was positive for syphilis, and she was admitted and treated with intravenous penicillin, with resolution of her uveitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Red eye is a common ocular symptom in patients presenting to the emergency department. The differential diagnosis of the red eye is broad and can range from benign etiologies, such as conjunctivitis, to life- and sight-threatening conditions, such as endogenous endophthalmitis. Systemic diseases such as syphilis may present with primarily ocular symptoms, and ocular syphilis must be identified and managed appropriately to prevent devastating sequelae.

Abnormal perception of pattern-induced flicker colors in subjects with glaucoma.

Pattern-induced flicker colors (PIFCs) are subjective colors that can be elicited with rotation of an achromatic stimulus such as the Benham disk. The perceptive mechanisms underlying PIFCs are not well-understood, but are thought to be generated primarily by retinal cell types which may be dysfunctional in glaucoma. Using a custom computer-based system, we tested PIFC perception across several Benham disk parameters, including the rates of acceleration and deceleration, rotational direction, and image contrast in both control and glaucoma subjects. We defined the Benham perception limit (BPL) during acceleration as the rotational speed at which PIFCs were first detected (Benham perception limit for acceleration) and the BPL during deceleration as the rotational speed at which PIFCs were extinguished (Benham perception limit for deceleration). In general, we found that glaucoma subjects perceived PIFCs less frequently than control subjects. For all subjects, we found that slower rates of acceleration and deceleration resulted in a lower Benham perception limit for acceleration and a higher Benham perception limit for deceleration, suggesting that PIFCs were both more easily detected and extinguished. Finally, subjects with glaucoma required increased rotational speeds during acceleration to detect PIFCs under certain conditions. Further study is needed to determine if these findings can be used to enhance clinical detection strategies.

Impact of the Texas-Wide Premedical Mentoring Program during the COVID-19 pandemic.

The COVID-19 pandemic disrupted the usual processes and support systems related to applying to medical school in the United States. The Texas-Wide Premedical Mentoring Program (TPMP) was established to pair medical student mentors in Texas with medical school applicants attending Texas colleges and universities. Our objective was to demonstrate the effect of the TPMP on application preparedness and self-reported mental health outcomes of program participants. A survey was developed to understand the program's impact on both mentees and mentors. Participants were sent a survey link 3 months after the TPMP launch. In total, 313 participants, comprising 62% premedical student mentees and 38% medical student mentors, completed the survey. Mentees reported a significantly positive effect of the program on anxiety, uncertainty of acceptance, connection to medicine, and making the road to medical school seem less impossible. After participation, mentees felt less alone and reported a positive impact on their perception of the application process. The TPMP positively impacted the mental wellness of both mentees and mentors, and about 80% of mentors felt more fulfilled despite not participating in clinical duties in light of suspensions. In conclusion, program participation was associated with decreasing application knowledge gaps, easing anxiety, and providing alliance for mentees. The TPMP had a similarly positive influence on the mental wellness of mentees and mentors as well as contributed to medical student mentors' sense of fulfillment.

Eyes of a Hurricane: The Effect of Hurricane Harvey on Ophthalmology Consultations at Houston's County Hospital.

OBJECTIVE: This study aimed to characterize ophthalmology consultations ordered after Hurricane Harvey compared to consultations ordered during the same time period of the prior year. METHODS: A retrospective chart review was performed at an urban, level 1 trauma center of a county hospital. All patients were included who received an electronic health record, documented ophthalmology consultation order between September 2017 and October 2017 (the time period immediately following Hurricane Harvey) or September 2016 and October 2016. Patient demographic risk factors were collected. Patient ICD10 clinical diagnoses were categorized as extraocular, intraocular, infectious, physiological, or other, and then subcategorized as trauma or non-trauma-related. A geographical heat map was generated to compare the changes in diagnosis volume by zip code to the magnitude of rainfall in the county. RESULTS: Following Hurricane Harvey, ophthalmology consultation volume decreased, number of infectious ophthalmology diagnoses increased (P < 0.001), percentage of patients on immunosuppression increased (P < 0.001), and the number of private insurance payers increased while the number of county-funded insurance payers decreased (P = 0.003). CONCLUSIONS: The risk of infectious eye diagnosis was double the risk of traumatic eye diagnosis from Hurricane Harvey flooding. During public disaster planning, different ophthalmological medical resources and responses should be considered for flooding versus high-wind events.

Learning to Interpret Pediatric Vocal Fold Mobility: A Laryngeal Ultrasound Training Module.

OBJECTIVES/HYPOTHESIS: Vocal fold movement impairment (VFMI) in infants and children is most commonly evaluated by flexible nasolaryngoscopy (FNL). FNL in this population can be challenging due to movement, floppy supraglottic structures, or secretions. Laryngeal ultrasound (LUS) may be an alternative, less invasive means of evaluating VFMI that also decreases aerosolization during the COVID-19 pandemic. The primary objective was to examine LUS interpretation proficiency for VFMI via an educational module. A secondary outcome was to determine whether quantitative measurements increase interpretation accuracy. STUDY DESIGN: Prospective cohort trial. METHODS: Medical students, residents, fellows, faculty, and staff were recruited to complete the module, composed of a 13-minute teaching video followed by 20 cases. Participants determined both qualitatively (subjective assessment) and then quantitatively (through protractor measurements of the vocal fold to arytenoid angle) whether there was normal versus impaired vocal fold mobility. RESULTS: Thirty participants completed the LUS training module, and about one-third were otolaryngology residents. On average, each participant correctly identified 18 cases. The mean rank percent correct for quantitative measurements was significantly higher than that of qualitative interpretations (P < .0001). Measurements significantly caused participants to change their answer correctly compared to incorrectly (P < .0001). As the module progressed, there was no significant trend of more correct interpretations (P = .30). The sensitivity was higher for quantitative interpretations (89.0% vs. 87.3%) but specificity remained unchanged (92.6%). CONCLUSION: Quantitative measurements may increase LUS interpretation accuracy. There was not a specific number of cases interpreted to achieve learning proficiency. LUS is an easily learned method to evaluate for VFMI across all training levels. LEVEL OF EVIDENCE: 3 (local cohort study nonrandomized) Laryngoscope, 131:2545-2549, 2021.

Bone conduction hearing device adherence in relationship to age in pediatric unilateral congenital aural atresia.

OBJECTIVE: To characterize the adherence of bone conduction hearing devices (BCHDs) for hearing management in children with unilateral congenital aural atresia (UCAA) in relation to the age of offer and fitting. BCHD Soft Bands help predict amplification benefits before surgery can be performed beginning around five years when both hearing and parental compliance reach stability. We hypothesized device compliance might decrease with age of fitting from lack of early acclimatization. METHODS: Retrospective case series of patients less than five years old at a tertiary pediatric center's microtia clinic database, born between 2014 and 2018 with UCAA. Adherence was assessed through electronic health record note documentation at less than 1 year, 1-2 years, and greater than 2 years from fitting. The ages at offer and fitting, along with the time from offer to fitting, were recorded. RESULTS: One hundred and eight patients with UCAA were identified, including 46 patients fit with a BCHD used for further analysis. Adherence rates at 1 year, 1-2 years, and greater than 2 years were 47.8%, 30%, and 43.5%, respectively. However, there was no significant association between age offered, age fit, or time from offer to fit and adherence at all time points. Also, there was no significant difference between ages at the time of BCHD offer for those who chose not to proceed with fitting (20.9 months) compared to the age of offer in patients that were subsequently fit (13.9 months). CONCLUSION: BCHD adherence in patients less than five years old may not be affected by the age offered or fit. The time between offer and fitting was also not associated with usage. BCHDs should be offered to UCAA patients regardless of age. Further investigation in this younger age group would help expand these findings.

Volumetric Analysis of the Vocal Folds Using Computed Tomography: Effects of Age, Height, and Gender.

OBJECTIVE: The goal of this study was to use computed tomography (CT) volumetric analysis to assess the effect of age, gender, height, body mass index (BMI), and ethnicity on vocal fold volume in patients with normal larynges. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Vocal fold length, width, and height were measured in a total of 105 patients without a history of laryngeal or thyroid pathology on thin-section soft-tissue neck CTs. The product of the three dimensions was used to calculate vocal fold volume. Simple and multiple linear regression analyses were used to assess for an association between vocal fold volume and age, gender, height, BMI, and ethnicity. Intraclass correlation coefficients (ICCs) were estimated to evaluate the degree interobserver and intraobserver agreement. RESULTS: Vocal fold volume was not associated with age, BMI, or ethnicity. Gender-adjusted height (P = .002) and height-adjusted gender (P = .016) were significantly associated with volume. Height remained significantly associated with volume after stratifying by gender (P < 0.001). There was moderate-to-good correlation in both interobserver (ICC = 0.690 to 0.761) and intraobserver (ICC = 0.733 to 0.873) agreement. CONCLUSION: Age was not associated with vocal fold volume, which is in accordance with several prior negative studies. Age-related vocal fold atrophy may not substantially contribute to presbyphonia symptoms, but other processes such as changes in the extracellular matrix may play a larger role. However, both gender and height were independently associated with vocal fold volume. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E240-E247, 2021.

A case of rare isolated agnathia and literature review.

Agnathia is a rare congenital malformation with unknown etiology characterized by absence of the mandible, microstomia, and tongue aplasia, often found to have other anomalies including holoprosencephaly. The purpose of this paper was to describe the symptoms and imaging of a case of isolated agnathia and to conduct a comprehensive literature review of reported patients with isolated agnathia. Case reports of isolated agnathia are very rare, with most infants as stillborn. We report a child's management of isolated agnathia with microstomia and tongue aplasia. A literature review was performed with focus on diagnosis, airway, and feeding management of isolated agnathia. Polyhydramnios was a common pregnancy complication reported in 25 out of the 39 patients in the case study. Five infants were stillborn, while 23 died within the neonatal period. Of the deceased infants within the neonatal period, 19 died within minutes to hours while four died within days to weeks. There are nine patients with agnathia that survived past infancy. The results of this study suggest that isolated agnathia is a rare malformation which requires a multi-disciplinary approach for airway and feeding management.

Cardiac anomalies in microtia patients at a tertiary pediatric care center.

OBJECTIVE: Microtia is a congenital condition that is known to be associated with cardiac abnormalities. Current guidelines suggest performing an echocardiogram or other cardiac work-up in the presence of ear anomalies with dysmorphic features but not isolated microtia. We report on the prevalence and characteristics of cardiac anomalies among microtia patients at a tertiary pediatric center. METHODS: A review of 428 children with microtia was conducted. Patients were identified as syndromic or non-syndromic. Data included echocardiograms performed, anomalies detected, need for cardiology follow-up, and need for surgical intervention. RESULTS: In the 428 patients with microtia, 77 patients (18%) were syndromic, the most common being Goldenhar (26%). 23.5% (101) of patients overall had documented echocardiograms, with structural anomalies found in 75.9% of patients screened and 18.5% overall, including disorders ranging from minor septal defects to Tetralogy of Fallot. The most common anomalies were left-right shunts in 77.2% of anomalies. Syndromic patients had a greater percentage of echocardiograms performed, cardiac anomalies, and cardiology follow-up compared to non-syndromic microtia patients. CONCLUSION: Children with microtia are at significant risk for cardiac abnormalities. Many patients with lesions required treatment and cardiology follow-up. Anomalies may have been missed in those who did not receive an echocardiogram. Given the risk of cardiac anomalies going unnoticed at the time of birth, we recommend a thorough cardiac physical exam for each microtia patient and the consideration of screening echocardiogram in syndromic children born with microtia.

Acquisition limitations of bone conduction hearing devices in children with unilateral microtia and atresia.

OBJECTIVE: To characterize the use of bone conduction hearing devices (BCHD) for hearing management in children with unilateral congenital aural atresia (CAA) at a tertiary pediatric center's microtia clinic while assessing challenges in acquisition. BCHD generally provides better audiologic outcomes than atresiaplasty in pediatric CAA. BCHD is formally recommended for only bilateral CAA, although literature has begun to show benefit in unilateral CAA. METHODS: A retrospective case series of patients born between 2014 and 2018 with unilateral microtia at an urban tertiary care children's hospital collected information on demographics, CAA laterality, hearing loss (HL) severity, management, and acquisition. Statistical analysis aided characterization of BCHD use. RESULTS: 131 patients (65% males) were included with a mean age of 3.5 years. 108 (82%) patients with unilateral microtia were used for further analysis, and right sided microtia was most common (67.6%). Of patients with auditory brain response (ABR) testing available, 70% demonstrated conductive HL, 16% mixed HL, 1% sensorineural HL, 6% no HL secondary to grade 1 microtia, and 7% were pending evaluation. Overall, 46 (42.6%) patients with unilateral microtia obtained a BCHD. 68.7% of those offered a BCHD after ABR opted for acquisition. The average length of time from offer to fit was about 6 months. CONCLUSION: Even with thorough consultation and follow up, less than half of the patients with unilateral CAA received a BCHD. Missed initial ABR appointments that lead to BCHD recommendation seem to be the greatest limiting factor, while demographics did not play a confounding role. Family education and future research on obstacles preventing BCHD use in unilateral CAA will help standardize management and improve hearing within this critical auditory period.

Recommendations for management of neonatal brachial plexus palsy: Based on clinical review.

STUDY DESIGN: Descriptive report. INTRODUCTION: Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births. PURPOSE OF THE STUDY: This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery. METHODS: Retrospective medical record audit from 2012 to 2017. RESULTS: Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly. DISCUSSION: From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created. CONCLUSIONS: Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.

One-step conversion of agro-wastes to nanoporous carbons: Role in separation of greenhouse gases.

Highly microporous carbons have been synthesized from four types of agro-wastes of lignin, walnut shells, orange peels and apricot seeds by one-step carbonization/activation with potassium hydroxide (KOH) in varying ratios. The resultant carbons demonstrated BET specific surface areas of 727-2254 m2/g, and total pore volumes 0.34-1.14 cm3/g. These are higher than the majority of agro-waste derived carbons reported in the literature. For all the carbons, CO2 adsorption at 298 K was higher than SF6 followed by N2 suggesting a possible separation of CO2 and SF6 from N2. The adsorbed amounts of CO2 at 298 K and 273 K and at pressures up to 760 Torr were 7.24 and 9.4 mmol/g, respectively which, to the best of our knowledge, are the highest CO2 uptakes in these temperatures by any carbon material reported so far. For all the gases, selectivity, mixed adsorption isotherms and adsorption breakthrough have been simulated from experimental data.

Synthesis of Nitrogen and Sulfur Codoped Nanoporous Carbons from Algae: Role in CO2 Separation.

Nitrogen and sulfur codoped and completely renewable carbons were synthesized from two types of algae, Spirulina Platensis and Chlorella Vulgaris, without any additional nitrogen fixation reaction. The type of activation agents, char-forming temperature, activation agent-to-char ratio, and activation temperature were all varied to optimize the reaction conditions for this synthesis. The maximum Brunauer-Emmett-Teller surface area and total pore volumes of the carbons were 2685 m2/g and 1.4 cm3/g, respectively. The nitrogen and sulfur contents of the carbons were in the range of 0.9-5.69 at. % and 0.05-0.2 at. %, respectively. The key nitrogen functionalities were pyridinic, amino, and pyridonic/pyrrolic groups, whereas the key sulfur functionalities were S-C, O-S-C, and SO x groups. CO2 adsorption isotherms were measured at 273, 298, and 313 K, and the ideal adsorbed solution theory was employed to calculate the selectivity of adsorption of CO2 over N2 and simulate binary adsorption isotherms. The adsorption results demonstrated that the CO2 adsorption amount and the heat of CO2 adsorption were higher for carbons with higher nitrogen content, confirming the influence of nitrogen functionality in CO2 adsorption. The overall results suggested that these algae-derived renewable carbons can serve as potential adsorbents for CO2 separation from N2.

Using electronic surveys to gather information on physician practices during a response to a local epidemic--Rhode Island, 2011.

BACKGROUND: Electronic invitations may improve physician response rates to participate in internet surveys administered by public health agencies. METHODS: Following an increase in reported HIV/syphilis co-infection diagnoses among men-who-have-sex-with-men in Rhode Island, we invited the state's 700 adult primary care and emergency medicine physicians via e-mail to participate in an online, multiple choice survey covering their knowledge, attitudes, and practices regarding sexually transmitted diseases and HIV testing and prevention. Survey invitations were released in three waves over 28 days, triggered by declining daily response rates. RESULTS: Among 53% (n = 372) who agreed to participate, 68% (n = 252) completed all questions. Response was higher among internal medicine physicians than either family medicine or emergency medicine physicians (63% vs. 20% and 19%, respectively; P<0.0001). Daily response rates were highest in the first 48 hours after sending a reminder e-mail. CONCLUSION: This approach supported the Rhode Island Department of Health in rapidly gathering useful physician practice information during an outbreak. Internet-based survey tools coupled with increased prevalence of mobile communication devices and social media could greatly decrease the time and cost of shoe-leather epidemiology.

Incarceration, community health, and racial disparities.

Several recent studies have shown that the racial disparities in U.S. mortality nearly disappear in prisons. We review the social determinants of the recent epidemic of incarceration, especially the war on drugs, and describe inmate morbidity and mortality within the context of U.S. health disparities. Incarceration provides an important public health opportunity to address health disparities by accessing a high-need, medically-underserved, largely non-White population, but it has also been associated with poor long-term health outcomes. Viewing incarceration within the context of community health and community life shows that the more equitable mortality rates among inmates are not evidence of the beneficial effects of incarceration so much as an indictment of disparities in the community at large. Because people of color are incarcerated far more frequently than Whites, the experience may ultimately exacerbate rather than mitigate health disparities.

Short communication: new HIV infections at Southern New England academic institutions: implications for prevention.

New HIV infections among younger men who have sex with men (MSM) in the United States are escalating. Data on HIV infections in college students are limited. In 2010, three MSM college students presented to our clinic with primary HIV infection (PHI) in a single month. To determine the number of college students among new HIV diagnoses, we reviewed clinical characteristics and molecular epidemiology of HIV-diagnosed individuals from January to December 2010 at the largest HIV clinic in Southern New England. PHI was defined as acute HIV infection or seroconversion within the last 6 months. Of 66 individuals diagnosed with HIV in 2010, 62% were MSM and 17% were academic students (12% college or university, 5% other). Seventy-three percent of students were MSM. Compared to nonstudents, students were more likely to be younger (24 versus 39 years), born in the United States (91% versus 56%), have another sexually transmitted disease (45% versus 11%), and present with PHI (73% versus 16%, all p-values<0.05). Thirty percent of individuals formed eight transmission clusters including four students. MSM were more likely to be part of clusters. Department of Health contact tracing of cluster participants allowed further identification of epidemiological linkages. Given these high rates of PHI in recently diagnosed students, institutions of higher education should be aware of acute HIV presentation and the need for rapid diagnosis. Prevention strategies should focus on younger MSM, specifically college-age students who may be at increased risk of HIV infection.