Gastric Bezoar: Retrieve it, Leave it, or Disbelieve it?

OBJECTIVES: To determine the demographics, potential risk factors, endoscopic interventions and outcomes relating to gastric bezoars in pediatric patients; and comparing results with previously published literature. METHODS: Retrospective series by chart review of patients identified by International Classification of Diseases-9 codes 938 and 935, using the following Medical Subject Headings: 1, term bezoar; 2, Keywords gastric bezoar∗ or gastric foreign body∗. RESULTS: Thirty pediatric patients between ages of 2 to 18 years were found with gastric bezoars, with a female predominance. Majority had a phytobezoar. Six patients were diagnosed with dysautonomia, implying possible role of autonomic dysfunction contributing to abnormal gastric retention. Frequent symptoms included abdominal pain, nausea and vomiting, a decrease in appetite, and unintentional weight loss. A higher prevalence of underlying gastrointestinal disorders was found in those with bezoars. Nuclear medicine gastric emptying scan performed in 13 children was significantly abnormal in only 4 of these children. Most patients were treated with endoscopic removal of the bezoar. Endoscopic removal was accomplished by Roth net, generally requiring multiple passes. At follow-up, most of the children had improvement of symptoms, with bezoar recurrence in 1 patient. CONCLUSIONS: This is to our knowledge the largest series of gastric bezoars in pediatrics. On the basis of our review, phytobezoars may be under-reported in pediatrics. Bezoars should be considered in children presenting with chronic abdominal pain, nausea, and vomiting; even in developmentally normal children and those with normal gastric emptying. We suggest that dysautonomia and underlying gastrointestinal disorders may be potential risk factors.

Medical Provider Promotion of Oral Health and Women's Receipt of Dental Care During Pregnancy.

Objectives Dental care during pregnancy is important. We examined whether promotion of oral health by medical providers during pregnancy and pregnant women's receipt of dental care improved between 2009 and 2012 in California. Methods We used population-based postpartum survey data collected during 2009 (n = 3105) and 2012 (n = 6810) to compare the prevalence of women's reports that, during pregnancy, (a) their medical providers discussed oral health and/or suggested they see a dentist, and (b) they received dental care. Results Between 2009 and 2012, the proportion of women reporting that their medical providers talked about oral health or referred them to a dentist increased significantly overall (from 36 to 42%, and 21-26%, respectively, p < 0.001). The proportion of women with a dental visit during pregnancy also increased, from 38% in 2009 to 42% in 2012 (p < 0.005). The improvements were largely among women of lower income and education levels, those covered by Medi-Cal, and Latinas. Women whose medical providers promoted oral health care were approximately two times more likely to report having had a dental visit during pregnancy, even after adjusting for several potential confounders. Conclusions for Practice Characteristics of women reporting that their medical providers promoted, and that they received, dental care during pregnancy in 2012 suggests that the increases in promotion and use of oral health care were largely concentrated among Medi-Cal recipients. Further improvement is needed for all populations of pregnant women. Both public and private providers need to incorporate promotion of and referral for dental care into routine prenatal care protocols.

Impaired Health-Related Quality of Life in Children and Families Affected by Methylmalonic Acidemia.

An understanding of health related quality of life (HRQoL) in children and families affected by methylmalonic acidemia (MMA) is important in planning counseling and therapeutic intervention. Liver transplantation (LT) is used as a treatment for MMA; however, its risks and benefits continue to be investigated. The purpose of this study was twofold: (1) to measure HRQoL in children and families affected by MMA using the Pediatric Quality of Life Inventory (PedsQL™) parent version, and (2) to assess the impact of LT on HRQoL by comparing LT and non-LT patient scores and free responses. Parents/caregivers reported lower scores on the majority of the PedsQL™ scales as compared to samples of healthy children, children with solid organ transplants for indications other than MMA, and families affected by chronic conditions. Scores for children with MMA were lowest in school and social functioning and scores for families were lowest in worry and activity impairment. There were no significant differences in LT and non-LT patient scores on the PedsQL™ scales. Our results document the negative impact of MMA on HRQoL.

Preparing to take the USMLE Step 1: a survey on medical students' self-reported study habits.

BACKGROUND: The USA Medical Licensing Examination Step 1 is a computerised multiple-choice examination that tests the basic biomedical sciences. It is administered after the second year in a traditional four-year MD programme. Most Step 1 scores fall between 140 and 260, with a mean (SD) of 227 (22). Step 1 scores are an important selection criterion for residency choice. Little is known about which study habits are associated with a higher score. OBJECTIVE: To identify which self-reported study habits correlate with a higher Step 1 score. METHODS: A survey regarding Step 1 study habits was sent to third year medical students at Tulane University School of Medicine every year between 2009 and 2011. The survey was sent approximately 3 months after the examination. RESULTS: 256 out of 475 students (54%) responded. The mean (SD) Step 1 score was 229.5 (22.1). Students who estimated studying more than 8-11 h per day had higher scores (p<0.05), but there was no added benefit with additional study time. Those who reported studying <40 days achieved higher scores (p<0.05). Those who estimated completing >2000 practice questions also obtained higher scores (p<0.01). Students who reported studying in a group, spending the majority of study time on practice questions or taking >40 preparation days did not achieve higher scores. CONCLUSIONS: Certain self-reported study habits may correlate with a higher Step 1 score compared with others. Given the importance of achieving a high Step 1 score on residency choice, it is important to further identify which characteristics may lead to a higher score.

Perceived access to health services and provider information and adverse birth outcomes: findings from LaPRAMS, 2007-2008.

OBJECTIVES: Despite targeted public health efforts, racial disparities and poor birth outcomes are still apparent, particularly in the southern United States. Previous research through qualitative and modest quantitative research demonstrates a possible link between disparities in patient-provider conversations during prenatal visits, perceived access to prenatal care, and poor birth outcomes. METHODS: A secondary analysis was conducted using data from the 2007-2008 Louisiana Pregnancy Risk Assessment Monitoring System to examine perceived access to healthcare services and information received and its impact on birth outcomes. Respondents consisted of 2460 white and black American women who recently experienced a live birth in the state of Louisiana. RESULTS: Racial disparities among Louisiana mothers were evident, with black mothers experiencing significant perceived lack of services or access to resources from a healthcare or insurance provider and poorer birth outcomes. White mothers reported experiencing less access based on the lack of vital prenatal care information from a healthcare provider. Self-perceived access was significantly associated with preterm birth for black women (odds ratio 2.94, 95% confidence interval 1-8; P < 0.05) and infant mortality for white women (odds ratio 340.5, confidence interval 36-999); P < 0.05). CONCLUSIONS: Findings support the need for a better understanding of discriminatory experiences and their impact on women's experiences during prenatal care and poor birth outcomes.

Do home visiting services received during pregnancy improve birth outcomes? Findings from Virginia PRAMS 2007-2008.

OBJECTIVES: Reducing poor birth outcomes are national and state priorities. At the national level participation in home visiting services has gained momentum with the recent appropriation of federal funds for states to implement evidence-based maternal and child health home visiting programs. The effects of having a home visit are unknown at the state level. DESIGN AND SAMPLE: Using cross-sectional data from 2007 to 2008 Virginia Pregnancy Risk Assessment and Monitoring System (PRAMS), maternal and infant outcomes were examined. Women who had a home visit during pregnancy were assigned into the home visiting (HV) participation group and those who did not were assigned to the HV Comparison group and used for the analysis. MEASURES: Bivariate analyses, Rao-Scott chi square tests, and multivariate logistic regression measured and quantified the association between HV participation and outcomes. RESULTS: The HV Participation group were 87.5% less likely to have a low birth weight infant (0.13, 95% CI: 0.020, 0.78), 4.5 times more likely to initiate breastfeeding (aOR: 4.5, 95% CI: 1.05, 19.54), and 39 times more likely to use contraceptives postpartum (aOR: 38.55, 95% CI: 3.14, 473.21). CONCLUSIONS: Receiving home visiting services during pregnancy increased breastfeeding initiation and postpartum contraceptive use while reducing the risk of low birth weight.

Acute multiple cranial neuropathy: An oculopharyngeal variant of Guillain-Barré Syndrome.

We report the case of a 20-year-old male who presented to us with acute bilateral multiple cranial neuropathy in the form of bilateral total ophthalmoplegia and bulbar dysfunction. The patient had normal haematological and biochemical investigations, however, cerebrospinal fluid (CSF) analysis showed raised protein (96mg/dl) in the second week of illness. Peripheral nerve conduction studies and an MRI of the brain were normal. The patient showed gradual improvement after three weeks of supportive treatment. Considering the course of illness and the clinical and investigational profile, a diagnosis of an oculopharyngeal variant of Guillain-Barré syndrome (GBS) was made.

Partner support and impact on birth outcomes among teen pregnancies in the United States.

PURPOSE: Despite hypothesized relationships between lack of partner support during a woman's pregnancy and adverse birth outcomes, few studies have examined partner support among teens. We examined a potential proxy measure of partner support and its impact on adverse birth outcomes (low birth weight (LBW), preterm birth (PTB) and pregnancy loss) among women who have had a teenage pregnancy in the United States. METHODS: In a secondary data analysis utilizing cross-sectional data from 5609 women who experienced a teen pregnancy from the 2006-2010 National Survey of Family Growth (NSFG), we examined an alternative measure of partner support and its impact on adverse birth outcomes. Bivariate and multivariable logistic regression were used to assess differences in women who were teens at time of conception who had partner support during their pregnancy and those who did not, and their birth outcomes. RESULTS: Even after controlling for potential confounding factors, women with a supportive partner were 63% less likely to experience LBW [aOR: 0.37, 95% CI: (0.26-0.54)] and nearly 2 times less likely to have pregnancy loss [aOR: 0.48, 95% CI: (0.32-0.72)] compared to those with no partner support. CONCLUSIONS: Having partner support or involvement during a teenager's pregnancy may reduce the likelihood of having a poor birth outcome.

Degree of glutathione deficiency and redox imbalance depend on subtype of mitochondrial disease and clinical status.

Mitochondrial disorders are associated with decreased energy production and redox imbalance. Glutathione plays a central role in redox signaling and protecting cells from oxidative damage. In order to understand the consequences of mitochondrial dysfunction on in vivo redox status, and to determine how this varies by mitochondrial disease subtype and clinical severity, we used a sensitive tandem mass spectrometry assay to precisely quantify whole blood reduced (GSH) and oxidized (GSSG) glutathione levels in a large cohort of mitochondrial disorder patients. Glutathione redox potential was calculated using the Nernst equation. Compared to healthy controls (n = 59), mitochondrial disease patients (n = 58) as a group showed significant redox imbalance (redox potential -251 mV ± 9.7, p<0.0001) with an increased level of oxidation by ∼ 9 mV compared to controls (-260 mV ± 6.4). Underlying this abnormality were significantly lower whole blood GSH levels (p = 0.0008) and GSH/GSSG ratio (p = 0.0002), and significantly higher GSSG levels (p<0.0001) in mitochondrial disease patients compared to controls. Redox potential was significantly more oxidized in all mitochondrial disease subgroups including Leigh syndrome (n = 15), electron transport chain abnormalities (n = 10), mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (n = 8), mtDNA deletion syndrome (n = 7), mtDNA depletion syndrome (n = 7), and miscellaneous other mitochondrial disorders (n = 11). Patients hospitalized in metabolic crisis (n = 7) showed the greatest degree of redox imbalance at -242 mV ± 7. Peripheral whole blood GSH and GSSG levels are promising biomarkers of mitochondrial dysfunction, and may give insights into the contribution of oxidative stress to the pathophysiology of the various mitochondrial disorders. In particular, evaluation of redox potential may be useful in monitoring of clinical status or response to redox-modulating therapies in clinical trials.