Beyond the Neonate: A Delayed Presentation of Congenital Diaphragmatic Hernia in a 17-Year-Old.

Congenital diaphragmatic hernia (CDH) is a rare anomaly resulting from incomplete closure of pleuroperitoneal canals during fetal development, often presenting with acute respiratory distress in neonates. This case report highlights a 17-year-old female with recurrent episodes of acute left upper quadrant (LUQ) pain and no history of trauma or dietary change. A computerized tomography (CT) scan taken during her second presentation to the emergency department led to a diagnosis of left-sided CDH. She later had a successful laparoscopic diaphragmatic repair surgery and has remained symptom-free for over a year. Late-presenting CDH indicates a rare subset of cases diagnosed after one month of age. Late presentations comprise 5-25% of cases and become increasingly rare with age. Unlike neonatal CDH, which is associated with several comorbidities, late presentations often manifest as a standalone anomaly. When the correct diagnosis is made, uncomplicated surgical repair yields excellent long-term outcomes. However, delayed and incorrect diagnoses can result in serious morbidity. Late-presenting CDH has diverse clinical presentations and can elude diagnostic imaging. As a result, there is a need for heightened clinical suspicion. This report aims to enhance awareness of late-presenting CDH and explore challenges to prompt, accurate diagnosis. Ultimately, this study implores clinicians to consider this condition in patients with unexplained respiratory or gastrointestinal symptoms.

Acute Visual Disturbances and Ataxia Secondary to Attempted COVID-19 Prophylaxis With Ivermectin in a Nine-Year-Old.

Ivermectin is an antiparasitic agent listed as an essential medication by the World Health Organization. Ivermectin utilization has increased due to the popular, though inaccurate, perception of its use in COVID-19 management. Poison Control Central calls regarding ivermectin toxicity have increased 245% since pre-pandemic baselines. This case study illustrates the clinical presentation of ivermectin toxicity in a nine-year-old child with acute vision changes and ataxia. The child was given 60 mg (1 mg/kg) of veterinary-grade ivermectin by a parent, 10 times the clinically recommended dose of 0.1 mg/kg, as prophylaxis after household exposure to COVID-19. Ten hours later, the child developed new-onset blurry vision, a perception of red dots in the peripheral vision, dizziness, and balance issues. Physical examination was notable for pulsating pupils, ataxia, and dysmetria. Symptoms resolved completely after 10 hours. Ivermectin ingestion is an important diagnostic consideration in children presenting with similar symptoms. We hope our case aids in the identification of ivermectin toxicity and hastens necessary supportive measures.

Wearable Technology Leads to Initial Workup of Graves' Disease in an Adolescent Female.

Graves' disease is the most common form of hyperthyroidism in the pediatric population. While the most prevalent symptoms seen in children with Graves' disease include goiter and excessive sweating (Minamitani et al., 2017), diagnosis is frequently delayed due to presentation with non-specific symptoms (Léger et al., 2018). This case report is of a 12-year-old female who presented to her pediatrician with a one month history of episodes of tachycardia both with physical exertion and at rest. Notably, these episodes were discovered on her electronic smartwatch by its heart rate monitoring feature. Further pertinent positives elicited in the patient's review of systems included increasing anxiety, diaphoresis, intermittent hand tremors, and recent weight loss. These findings led to further workup that included thyroid studies, culminating in a diagnosis of Graves' disease. Indeed, this patient's smartwatch aided in her initial presentation to her physician and allowed for prompt workup and diagnosis. There exist limited studies to date on the use of smartwatches to detect cardiac-related conditions in children, which may be due to the absence of Food and Drug Administration approval for certain cardiac-related smartwatch features in this patient population.

Talon Noir in a Young Baseball Player: A Case Report.

When evaluating pediatric patients with hyperpigmented lesions on the plantar aspect of the feet, the differential diagnosis should include talon noir, acral melanoma, and verruca with thrombosis. Talon noir are asymptomatic brown-black pigmented macules formed by intraepidermal hemorrhages of the feet caused by shear-force injury. Spontaneous resolution of talon noir typically occurs within 2-3 weeks. Clinicians should ensure that their patients who participate in sports have appropriately fitting shoes, which may prevent these lesions from occurring. This case report highlights a unique case of talon noir occurring in a young baseball player with an atypical distribution of plantar macules.

Performance and Impact of a CLIA-waived, Point-of-care Respiratory PCR Panel in a Pediatric Clinic.

BACKGROUND: Laboratory-based respiratory polymerase chain reaction (PCR) panels are rarely used in outpatient pediatric practice due to prolonged turn-around times and cost of medical equipment. The BioFire FilmArray Respiratory Panel EZ (RP EZ) is a Clinical Laboratory Improvement Amendments-waived respiratory pathogen PCR panel which rapidly tests for 14 common respiratory organisms. The aim of this study was to identify the distribution of organisms seen in pediatric clinics and to determine if utilization of this point-of-care test improved disease management, while exploring impact on clinic workflow. METHODS: From January 2018 through January 2019, when clinically appropriate, patients were tested by the RP EZ and/or antigen tests (Clinic A) or antigen test only (Clinic B). Residual samples from Clinic B antigen tests were frozen and later tested on the RP EZ for definitive pathogen identification. Patient data and prescription records were extracted from the electronic health record. RESULTS: A total of 430 patients had RP EZ tests performed, and at least 1 organism was detected in 70.4% of patients. The most common organisms identified were human rhinovirus/enterovirus, influenza, and respiratory syncytial virus. Appropriate treatment occurred for 93.6% of patients when the RP EZ was performed (Clinic A) versus 87.9% of patients who had only antigen tests performed (Clinic B, P = 0.0445). Utilization of RP EZ testing also significantly reduced appointment duration time (48.0 versus 54.9 minutes, P = 0.0009). Three false-positive influenza B results were identified by antigen testing. CONCLUSIONS: A point-of-care PCR panel improved patient care by providing an accurate diagnosis and shortened appointment duration.

Teaching Students How to Improve Safety and Quality in Two Children's Hospitals: Building a Pediatric Clerkship Patient Safety and Quality Experience.

This report describes a novel method to enhance medical student understanding of systems-based practice and patient safety through experiential learning, assessing the perceived value of student-identified patient safety and systems vulnerabilities, and their proposed interventions at academic children's hospitals.

Rectal Bleeding and Abdominal Pain Following Vaccination in a 4-Month-Old Infant.

Intussusception is one of the most frequent causes of intestinal obstruction in infants. Rotavirus vaccination has been associated with intussusception in the medical literature. We report a case of a 4-month-old female with intussusception requiring hemicolectomy one week following rotavirus vaccination. We review the pathophysiology, presentation, and management of intussusception with a distinct focus on the history of rotavirus vaccination and risks of intussusception associated with timing of rotavirus vaccine administration. The discussion makes a strong case for rotavirus vaccine counseling regarding signs of intestinal obstruction and the importance of early recognition.

Recognizing and treating anxiety disorders in children.

Anxiety disorders are a common group of disorders that must be recognized more frequently by pediatricians. Outcomes can be very successful with prompt recognition and early treatment. For this reason, it is important that pediatricians recognize their central role in integrating sociological, psychological, and biological approaches to treatment. Pediatricians are vital for initial assessment, interventions, management of psychotherapeutic and pharmacotherapeutic treatments, and referral to psychiatrists and psychologists when necessary. An improved understanding of anxiety disorders by pediatricians will lead to improved diagnosis and improved quality of life for many undiagnosed pediatric patients suffering from anxiety.

Brothers with Smith-Lemli-Opitz syndrome.

Abnormal cholesterol metabolism is the cause of SLOS, with low cholesterol levels and elevated levels of cholesterol precursors thought to contribute to the clinical findings in this syndrome. Management of SLOS involves early intervention with appropriate therapies for identified disabilities, genetic counseling for families, nutritional consultations, educational interventions, and behavioral management. Although no randomized dietary studies have been conducted, cholesterol supplementation continues to be a common recommendation for persons with SLOS, because it may result in clinical improvement and has few adverse effects (Nowaczyk, 2013). Even with early detection and treatment (e.g., sibling B in this case report), persons with SLOS often have significant behavioral issues and cognitive and developmental delays that require a team approach by parents, educators, specialists, and primary care providers.

Symptomatic atlantoaxial instability in an adolescent with trisomy 21 (Down's syndrome).

Atlantoaxial instability (AAI) occurs in 15% of children with Trisomy 21. Health supervision guidelines were revised by the American Academy of Pediatrics in 2011 to reflect advances in care for children with special health care needs (CSHCN). Previous guidelines recommended cervical spine radiological screenings in preschool years to evaluate for atlantoaxial instability. For patients with negative screening, re-screening was recommended if they wished to compete in the Special Olympics, or became symptomatic. We present the case of an adolescent who developed a symptomatic atlantoaxial dislocation despite previous negative radiological screening at the age three (under the 2001 guidelines). This case report highlights the revisions in the 2011 guidelines for health supervision and anticipatory guidance. It underlines the need for a high index of suspicion if symptoms develop. It also addresses the need for a medical home for CSHCN, with health care providers who know the child's baseline health status.

Family-centered rounds and medical student education: a qualitative examination of students' perceptions.

BACKGROUND: Although current literature supports the benefits of family-centered rounds on medical education, few studies have explored students' perceptions of family-centered rounds. PURPOSE: The aim of this study was to provide a better and broader understanding of the effect of family-centered rounds on medical student education. METHODS: During the inpatient portion of the third-year pediatric clerkship at a southeastern United States 4-year medical school, students were exposed to family-centered and conference room work rounds and completed a post-hoc reflective open-ended questionnaire. The study was conducted from July to December 2007 and the inpatient experience was at one of two large academic medical centers. Using a constant comparative approach, the qualitative content of 45 of the 63 potential students' responses was analyzed. RESULTS: Family-centered rounds served as an opportunity for medical students to build their practice-based knowledge through direct and simultaneous interaction with the medical team, patients, and families. Family member communication, medical team communication, and increased exposure to patients allowed for unique learning opportunities such as augmentation of communication skills, practice with use of lay terms, legitimate peripheral participation, and humanizing cognitive understanding of diseases. Areas of concern noted by the students included space limitations, length of rounds, potential anxiety provoked in the patient, and faculty and resident comfort with teaching certain topics. CONCLUSIONS: Our qualitative analysis of medical student perceptions on family-centered rounds suggests that pediatric medical student education may benefit by improving knowledge and practice with communication and humanizing disease processes. However, perceived barriers, such as concerns about space or instructor comfort with teaching certain topics, existed. Further studies are warranted to gain a better understanding of the educational impact of conducting this type of rounds.

Pediatric residents' learning styles and temperaments and their relationships to standardized test scores.

BACKGROUND: Board certification is an important professional qualification and a prerequisite for credentialing, and the Accreditation Council for Graduate Medical Education (ACGME) assesses board certification rates as a component of residency program effectiveness. To date, research has shown that preresidency measures, including National Board of Medical Examiners scores, Alpha Omega Alpha Honor Medical Society membership, or medical school grades poorly predict postresidency board examination scores. However, learning styles and temperament have been identified as factors that 5 affect test-taking performance. The purpose of this study is to characterize the learning styles and temperaments of pediatric residents and to evaluate their relationships to yearly in-service and postresidency board examination scores. METHODS: This cross-sectional study analyzed the learning styles and temperaments of current and past pediatric residents by administration of 3 validated tools: the Kolb Learning Style Inventory, the Keirsey Temperament Sorter, and the Felder-Silverman Learning Style test. These results were compared with known, normative, general and medical population data and evaluated for correlation to in-service examination and postresidency board examination scores. RESULTS: The predominant learning style for pediatric residents was converging 44% (33 of 75 residents) and the predominant temperament was guardian 61% (34 of 56 residents). The learning style and temperament distribution of the residents was significantly different from published population data (P  =  .002 and .04, respectively). Learning styles, with one exception, were found to be unrelated to standardized test scores. CONCLUSIONS: The predominant learning style and temperament of pediatric residents is significantly different than that of the populations of general and medical trainees. However, learning styles and temperament do not predict outcomes on standardized in-service and board examinations in pediatric residents.