Anisocoria secondary to antiperspirant wipes in a pediatric population: a case series.

Acute-onset anisocoria or mydriasis in children carries a broad differential diagnosis and includes both benign and life-threatening causes, ranging from systemic or topical drug use to peripheral or central nervous system disease. The topical anticholinergic agent glycopyrronium (approved by the Food and Drug Administration in June 2018) is used to treat hyperhidrosis. We present the first case series of pediatric patients presenting with acute mydriasis due to exposure to glycopyrronium wipes. Six cases (ages 12-16) were identified: 3 presented emergently and 3 to a primary care physician. Additional symptoms included blurry vision (4/6) and unilateral headache (1/6). In 3 cases, use of glycopyrronium wipes was not elicited initially, neuroimaging was obtained, and ophthalmology (2/3) or neurology (1/3) was consulted. One patient remained undiagnosed and presented emergently again 2 months later. In all patients, symptoms resolved without further treatment.

Chemoprotection with botulinum toxin following proximal hamstring-Ischial tuberosity avulsion fracture repair: Running title: Chemoprotection for hamstring avulsion fractures.

INTRODUCTION: Surgical treatment for avulsion injuries of the proximal hamstrings has gained increasing popularity over the past decade. Despite good outcomes, early failures have been noted and have been attributed to slipping and falling, postoperative muscle spasm, or early mobilization. In a recent review of hamstring repair rehabilitation protocols, it was shown that there is marked variability in post-operative management. Post-operative bracing with limiting knee extension and hip flexion is the standard of care in most early rehabilitation protocols. Braces with limitation of hip flexion and knee locked in 900 flexion can be awkward, cumbersome and create fall risk.Chemoprotection has more recently been proposed to be an alternative approach to prevent tendon repair failure and controlled mobilization which has been shown to be superior to complete immobilization. We present the first case series of the use of botulinum toxin for chemo-protection of the proximal hamstring ischial avulsion repair, demonstrating its safety and efficacy. METHODS: Retrospective case series at a tertiary children's hospital which included patients <18 years of age who underwent interventional treatment for proximal hamstring avulsion injuries of the ischium utilizing botulinum toxin as a chemoprotective agent. Data collected included demographic data, injury and treatment details, imaging, post-operative rehabilitation and return to activity. Descriptive statistical analysis was conducted. RESULTS: Five male patients with mean age 14 years (12-17) were included in the study. All were sports related non-contact injuries. Radiographs showed displaced avulsion fractures in all 5 patients. All patients had failed conservative management initially; mean time to surgery from initial injury was 34.4 weeks. 4 patients underwent open reduction and internal fixation (ORIF), 1 patient with less displacement had bone marrow aspirate (BMA) injection; all had chemoprotection using botulinum toxin injected in the hamstrings. No patient required hip immobilization or knee immobilization locked to 90°. We elected to use a brace locked at 20° knee flexion in 2/5 patients. All patients underwent supervised physical therapy and achieved symmetric knee range of motion (ROM). Post-operative radiographs confirmed healing of the avulsion fracture in all 5 patients and they all returned to previous level of activity at mean 32 weeks (21-43) from surgery. None of the patients had a hamstring re-injury at mean follow up of 27 months (11-42). CONCLUSION: Our case series is the first in literature that shows the safety and efficacy of chemoprotection with botulinum toxin for the post-operative management of avulsion injuries of proximal hamstrings, by minimizing the need for cumbersome bracing and allowing controlled motion during physical therapy.

Abnormal Red Reflex: Etiologies in a Pediatric Ophthalmology Population.

Children who present with an abnormal red reflex (ARR) are often referred to ophthalmology due to concern for retinoblastoma. However, an ARR can indicate a wide variety of pathologies, all of which have the potential to develop amblyopia and irreversible vision loss. In this retrospective cohort study, we demonstrate that children who presented with an ARR had a mean age of 22.0 ± 32.5 months and were more frequently referred by their pediatricians (74.5%). The majority of these patients (61.8%) had a normal examination on further evaluation, followed by refractive error (20.4%). Amblyopia was diagnosed in 83.9% of patients with refractive error, with a mean age of 50.3 ± 49.2 months. Because many ARR-associated pathologies require time-sensitive treatment to prevent vision loss, proper screening is critical for diagnosis. Pediatricians play a key role in screening, so education on more common ARR pathologies can better facilitate referrals and improve outcomes.

Electronic cigarette and combustible cigarette use following a campus-wide ban: Prevalence of use and harm perceptions.

The current study examined changes in prevalence of e-cigarette use and perceptions of the harmfulness of e-cigarette and combustible cigarettes following a campus-wide tobacco ban. Undergraduate students completed surveys of tobacco use and perceived product harmfulness. Four samples were collected: in 2013 prior to the ban (n = 792) and in fall 2014 (n = 310), 2015 (n = 208), and 2016 (n = 417). E-cigarette use increased in the years following the ban (p = .01) while combustible cigarette use decreased from 2013 to 2016 (p = .02). Men were more likely than women to use both products (ps < .05). Students' perceptions of the harmfulness of combustible and electronic cigarettes remained stable in the years following the ban (p > .05). This study is the first to examine the impact of including e-cigarettes in tobacco free policies. Combustible cigarette use declined, but e-cigarette use increased in the years following the e-cigarette ban. Prospective research is needed to understand the long-term impacts of e-cigarette bans.

Distress Tolerance Links Sleep Problems with Stress and Health in Homeless.

OBJECTIVE: We examined associations between sleep problems, distress intolerance, and perceived stress and health in a convenience sample of homeless adults. METHODS: Participants (N = 513, 36% women, Mage = 44.5 ±11.9) self-reported sleep adequacy, sleep duration, unintentional sleep during the daytime, distress tolerance, urban stress, and days of poor mental health and days of poor physical health over the last month. The indirect effects of sleep problems on stress and health through distress tolerance were examined using a non-parametric, bias-corrected bootstrapping procedure. RESULTS: Sleep problems were prevalent (eg, 13.0 ±11.4 days of inadequate sleep and 4.7 ±7.9 days of unintentionally falling asleep during the preceding month). Distress intolerance partially accounted for the associations of inadequate sleep and unintentionally falling asleep, but not sleep duration, with urban stress and more days of poor mental and physical health. CONCLUSIONS: Many homeless individuals endure sleep problems. Given the connections between sleep and morbidity and mortality, results further support the need for more attention directed toward facilitating improvements in sleep quality to improve the quality of life of homeless adults, potentially including attention to improving distress tolerance skills.

Determinants of social status among homeless adults.

OBJECTIVES: To examine determinants of subjective social status (SSS) among 394 sheltered homeless adults. METHODS: Demographics, socioeconomic status, homelessness, and other life factors were examined as potential determinants of US and Community SSS using parametric tests. RESULTS: Higher income, African-American/other race, having health insurance, being employed, having longer duration of homelessness, having children, and being of non-veteran status were each significantly associated with higher SSS-US. African-American/ other race and having health insurance were significantly associated with higher community SSS. Variables maintained significance in multivariate models except homelessness duration (for SSS-US). CONCLUSIONS: Given known relations of SSS and negative health behaviors and outcomes, understanding the correlates of SSS among homeless adults may facilitate targeted interventions.

Mental illness and substance use problems in relation to homelessness onset.

OBJECTIVES: The relationships among youth (≤ 24 years) versus adult (>24 years) homelessness onset, lifetime serious mental illness, and substance use problems is not well understood. We sought to explore these associations among 394 homeless adults, 124 of whom reported youth-onset homelessness. METHODS: Covariate-adjusted logistic regression analyses evaluated the associations among homelessness onset, serious mental illness, and self-reported substance use problems. RESULTS: Youth-onset homelessness was associated with greater likelihood of serious mental illness and sedative problems, and a lower likelihood of cocaine problems, in adjusted analyses (p values ≤ .04). CONCLUSIONS: Serious mental illness and sedative problems may characterize homeless youth who are vulnerable to adulthood homelessness, although longitudinal cohort studies are needed to explicate temporal relations between variables.