Computed tomographic findings in a canine ovarian teratoma.

A 2-year-old, intact female, Labrador Retriever was referred for progressive abdominal distension, assessed by emergency clinicians as being extrauterine in origin on AFAST. Abdominal radiographs and ultrasound identified a large, lobulated, partially mineralized, soft tissue, mid-abdominal mass and gravid uterus. Contrast-enhanced CT identified a mixed fat to soft tissue attenuating mass with a complex internal mineralized matrix, heterogeneous contrast enhancement, receiving blood from the left ovarian artery. Histology confirmed a left ovarian teratoma, diffuse endometrial hyperplasia, and fetal implantation. The patient had a good post-operative outcome for 2 years, but was later diagnosed with primary cranial mediastinal neuroendocrine carcinoma.

Impact of simulated MitraClip on forward flow obstruction in the setting of mitral leaflet tethering: An in vitro investigation.

OBJECTIVES: We aimed to evaluate diastolic leaflet tethering as a factor that may cause mitral stenosis (MS) after simulated MitraClip implantation, using an in vitro left heart simulator. BACKGROUND: Leaflet tethering commonly seen in functional mitral regurgitation may be a significant factor affecting the severity of MS after MitraClip implantation. METHODS: A left heart simulator with excised ovine mitral valves (N = 6), and custom edge-to-edge clip devices (GTclip) was used to mimic implantation of MitraClip in a variety of positions. Anterior mitral leaflet (AML) tethering severity was varied for each case (leaflet excursion of 75°, 60°, and 45°, consistent with mild, moderate and severe tethering), and the baseline mitral annular area (MAA) was varied across samples (3.6-4.8 cm2 ). The resulting mitral valve area (MVA), and peak/mean mitral valve gradient (MVG) were measured in each case. RESULTS: AML tethering severity was a highly significant factor increasing MVG and decreasing MVA (P < 0.001). When GTclip placement was simulated with severe AML tethering, mean MVG >5 mmHg resulted more frequently than with GTclip placement alone (46% vs. 4%, respectively). However, severe AML tethering alone significantly reduced baseline MVA to 3.6 ± 0.2 cm2 , and increased baseline MVG to 3.0 ± 0.4 mmHg. At MAA above 4.7 cm2 , severe AML tethering did not cause moderate MS, even with placement of two GTclips (95% confidence). CONCLUSIONS: Our results show that diastolic AML tethering may predispose to MS after clip placement, however, MS was not observed when baseline MVA was above 4.0 cm2 . Severity of AML tethering may be an important criterion in selecting patients for edge-to-edge repair.

Impact of Health Insurance Contract Timing on Breast Reconstruction Completion.

BACKGROUND: Cost of breast reconstruction can create a substantial burden for patients. As patients hope to maximize insurance plan benefits, it is crucial to receive efficient, cost-reducing care. This study analyzes the impact of insurance cycle [calendar-based insurance (CBI) versus non-calendar-based insurance (NCBI)] on breast reconstruction. METHODS: Between January of 2014 and 2018, patients undergoing postmastectomy breast reconstruction performed by two senior surgeons (N.T.H. and S.S.T.) at a single academic institution were retrospectively evaluated. Data were collected on insurance contract timing (CBI versus NCBI) and insurance payor. RESULTS: A total of 514 patients were included: 136 patients on NCBI and 378 patients on CBI. Individuals enrolled in CBI were more likely than NCBI patients to have their last operation toward the end of the calendar year ( P < 0.0005). In addition, individuals on private CBIs are more likely to have their last operation closer to the end of the year than those on public CBIs ( P < 0.0001). Individuals enrolled in CBI were less likely to receive autologous reconstruction than individuals on NCBI ( P = 0.011). Among patients on private CBIs, patients with all major revisions were more likely to start their reconstructive journey earlier in the year than patients who did not finish major revisions ( P = 0.011). Lastly, individuals on private insurance also undergo more revision procedures than those on public insurance ( P < 0.0001). CONCLUSIONS: Insurance contract cycle and payor impact the timing of breast reconstruction. This study emphasizes the importance of both patient and provider working toward maximizing health insurance plan benefits.

The Effects of High Deductible Health Plans on Breast Cancer Treatment and Reconstruction.

BACKGROUND: High-deductible health plans (HDHP) have expanded rapidly creating the potential for substantially increased out-of-pocket (OOP) costs. The associated financial strain has been associated with the decision to forego care, but the impact on patients undergoing breast cancer reconstruction is not known. We examined the impact of HDHPs vs. LDHPs and OOP maximums on breast reconstruction. METHODS: Between January 2014 and 2020, patients who had breast reconstruction by the 2 senior authors were retrospectively evaluated. Information on patient's insurance contract was collected. Criteria for HDHP and LDHP were defined following section 223(c)(2)(A) of the Internal Revenue Code. All aspects of cancer diagnosis, cancer treatment, and surgical procedures were reviewed. RESULTS: About 507 patients (262 in LDHPs and 245 in HDHPs) were reviewed. Patients treated with neoadjuvant chemotherapy were more likely to be enrolled in HDHPs (25.7% vs. 36.8%, P < .01). There was no significant difference in total operations, number of revisions, or length of reconstruction in days or calendar years. Additionally, no difference existed in the choice of autologous implant reconstruction. CONCLUSION: The cost-sharing burden of HDHPs creates the potential for patients to forego care, and thus, effort should be directed toward increasing patient education concerning health plan benefits. Utilization of postdeductible spending, as well as resources of health savings accounts, may limit the adverse effects of HDHPs. This study also emphasizes the importance for providers to increase cost transparency.

Reconstructive Burnout after Mastectomy: Implications for Patient Selection.

BACKGROUND: The reconstructive journey after mastectomy can be a long road, with many hurdles to achieve an ideal aesthetic result. Cancer therapy, operative complications, and comorbidities impact patients physically and emotionally. This study introduces the term reconstructive burnout and aims to evaluate which factors predict and contribute to patients prematurely stopping reconstruction. METHODS: The authors performed a retrospective review of patients undergoing breast reconstruction after skin-sparing mastectomy from 2014 to 2017 performed by two senior surgeons (N.T.H. and S.S.T.) at a single institution. Reconstructive burnout is defined as either no breast mound creation or completion of the breast mound without completion of all major revisions. RESULTS: A total of 530 patients were included, with 76.6% completing reconstruction. In patients undergoing delayed-immediate reconstruction, patients with wounds ( P = 0.004), infections ( P = 0.037), or a complication requiring operative intervention ( P < 0.001) were correlated with incomplete reconstruction; explantation of expanders was highly correlated with reconstructive burnout ( P < 0.001). Implant-based and autologous reconstruction had comparable burnout rates (17.1% versus 19.1%; P = 0.58). Logistic regression models found high body mass index, radiation therapy, any tissue expander complication, and tissue expander explantation to be significant predictors of burnout. Autologous reconstruction was the strongest predictor of completion of reconstruction in both univariable and multivariable models. CONCLUSIONS: Reconstructive burnout in breast reconstruction is associated with tissue expander complications, high body mass indices, and radiation therapy. Overall rates of burnout were comparable between autologous and implant-based reconstruction, with autologous reconstruction being the strongest predictor of completion of reconstruction. It is critical to tailor each patient's reconstructive journey to meet both their emotional and physical needs to avoid reconstructive burnout.

Distinguishing Incomplete Kawasaki and Nonsevere Multisystem Inflammatory Syndrome in Children.

OBJECTIVES: Characterizing inflammatory syndromes during the coronavirus disease 2019 pandemic was complicated by recognition of multisystem inflammatory syndrome in children (MIS-C), contemporaneous with episodes of Kawasaki disease. We hypothesized a substantial overlap between the 2 and assessed the performance of an MIS-C likelihood score in differentiating inpatients with nonsevere MIS-C from prepandemic incomplete Kawasaki disease (iKD) without coronary involvement. METHODS: A retrospective review of inpatient records was conducted; the nonsevere MIS-C cohort (March 2020-February 2021) met the 2023 definition for MIS-C; the iKD cohort (January 2018-January 2019) met the American Heart Association criteria for iKD without coronary involvement. We applied the likelihood score to both cohorts. We estimated the percent of children with iKD who could have met the clinical criteria of the MIS-C, had they presented in 2023. RESULTS: The 68 children in the nonsevere MIS-C cohort were older (8 vs 4 years, P < .001) than the 28 children in the iKD cohort. Those in the nonsevere MIS-C cohort had higher rates of thrombocytopenia (P < .001) and lymphopenia (P = .021); those in the iKD cohort had higher rates of pyuria (P < .001). Twenty-four (86%) children in the iKD cohort met the 2023 MIS-C definition. The scoring system correctly predicted 71% to 74% children with their respective clinical diagnoses. CONCLUSIONS: Though there was considerable clinical overlap, thrombocytopenia, lymphopenia, and the absence of pyuria were the most helpful parameters to distinguish children with nonsevere MIS-C from those with iKD.

Guardians' Self-Reported Fair/Poor Oral Health Is Associated with Their Young Children's Fair/Poor Oral Health and Clinically Determined Dental Caries Experience.

In this cross-sectional, community-based study among a multi-ethnic sample of preschool-age children in North Carolina, United States, we sought to quantify the association between guardians' self-reported oral health and their children's oral health and determine whether race/ethnicity and education level modify these associations. We used questionnaire (n = 7852) responses about caregivers' and their children's oral health and clinical examination-derived (n = 6243) early childhood caries (ECC) status defined at the ICDAS ≥ 3 caries lesion detection threshold. We used multi-level mixed-effects generalized linear models to examine the associations between the guardians' reported oral health and their children's reported and clinically determined oral health among the entire sample and within strata of race/ethnicity, guardians' education, and children's dental home. The guardians' and their children's reported fair/poor oral health (FPOH) were 32% and 15%, respectively, whereas 54% of the children had ECC and 36% had unrestored disease. The guardians' FPOH was strongly associated with their children's FPOH (average marginal effect (AME) = +19 percentage points (p.p.); 95% CI = 17-21), and this association was most pronounced among Hispanics, lower-educated guardians, and children without a dental home. Similar patterns, but smaller-in-magnitude associations, were found for the guardians' FPOH and their children's clinically determined ECC (AME = +9 p.p.; 95% CI = 6-12) and unrestored disease (AME = +7 p.p.; 95% CI = 4-9). The study's findings support a strong association between guardians' and their children's reported and clinically determined oral health and implicate ethnicity, education, and having a dental home as factors possibly modifying the magnitude of these associations.

Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children.

Importance: Optimal agents and duration of primary treatment for multisystem inflammatory syndrome in children (MIS-C) remain unclear. Objective: To compare short-term patient outcomes based on initial treatment with corticosteroids, intravenous immunoglobulin (IVIG), or both. Design, Setting, and Participants: This retrospective cohort study included patients in a tertiary-care pediatric hospital system who had MIS-C per the Centers for Disease Control and Prevention case definition during the period March 2020 to February 2021. Exposures: Immunomodulatory therapy within the first 24 hours (patients in the intensive care unit [ICU]) or 48 hours (non-ICU patients): corticosteroids alone, IVIG alone, and IVIG plus corticosteroids. Main Outcomes and Measures: Primary outcome was failure of initial therapy, defined as therapy escalation due to fever or worsening or lack of improvement of laboratory, cardiac, or noncardiac clinical factors after 24 hours (ICU patients) or 48 hours (non-ICU patients) from time of therapy initiation, per clinician assessment. Secondary outcomes included presence of complications, cardiovascular outcomes, fever duration, length of hospital and ICU stays, corticosteroid use duration, and need for readmission. Results: Among 228 eligible patients, 215 patients were included in the univariate analysis; median age was 8 years, and 135 (62.8%) were boys. There were 69 patients in the corticosteroids group, 31 patients in the IVIG group, and 115 patients in the IVIG plus corticosteroids group. Patients in the corticosteroids group had milder disease at presentation. After propensity score weighting including 179 patients (68 in the corticosteroids group and 111 in the IVIG plus corticosteroids group), rates of initial treatment failure were similar between groups. Among patients whose initial treatment failed, treatment failure in the IVIG plus corticosteroids group was more likely to be based on laboratory parameters (odds ratio [OR], 1.96; 95% CI, 1.07-3.60) and less likely to be based on cardiovascular markers (OR, 0.39; 95% CI, 0.2-0.76), per clinician assessment. Patients in the IVIG plus corticosteroids group had a longer median inpatient stay (6 vs 5 days; P = .001) and longer median corticosteroid course duration (10 vs 5 days; P = .04) compared with the corticosteroids group. Forty-nine patients (71% of 69 in the corticosteroids group) recovered after receiving corticosteroid monotherapy for 10 days or less. Conclusions and Relevance: Corticosteroid monotherapy is a reasonable management option for a subset of patients with MIS-C, particularly those with mild disease.

Distinguishing Multisystem Inflammatory Syndrome in Children From COVID-19, Kawasaki Disease and Toxic Shock Syndrome.

BACKGROUND: Distinguishing multisystem inflammatory syndrome in children (MIS-C) from coronavirus disease 2019 (COVID-19), Kawasaki disease (KD), and toxic shock syndrome (TSS) can be challenging. Because clinical management of these conditions can vary, timely and accurate diagnosis is essential. METHODS: Data were collected from patients <21 years of age hospitalized with MIS-C, COVID-19, KD, and TSS in 4 major health care institutions. Patient demographics and clinical and laboratory data were compared among the 4 conditions, and a diagnostic scoring tool was developed to assist in clinical diagnosis. RESULTS: A total of 233 patients with MIS-C, 102 with COVID-19, 101 with KD, and 76 with TSS were included in the analysis. Patients with MIS-C had the highest prevalence of decreased cardiac function (38.6%), myocarditis (34.3%), pericardial effusion (38.2%), mitral regurgitation (31.8%) and pleural effusion (34.8%) compared with patients with the other conditions. Patients with MIS-C had increased peak levels of C-reactive protein and decreased platelets and lymphocyte nadir counts compared with patients with COVID-19 and KD and elevated levels of troponin, brain natriuretic peptide and pro-brain natriuretic peptide compared with COVID-19. Diagnostic scores utilizing clinical findings effectively distinguished MIS-C from COVID-19, KD, and TSS, with internal validation showing area under the curve ranging from 0.87 to 0.97. CONCLUSIONS: Compared with COVID-19, KD, and TSS, patients with MIS-C had significantly higher prevalence of cardiac complications, elevated markers of inflammation and cardiac damage, thrombocytopenia, and lymphopenia. Diagnostic scores can be a useful tool for distinguishing MIS-C from COVID-19, KD, and TSS.

Serologic and Cytokine Signatures in Children With Multisystem Inflammatory Syndrome and Coronavirus Disease 2019.

BACKGROUND: The serologic and cytokine responses of children hospitalized with multisystem inflammatory syndrome (MIS-C) vs coronavirus disease 2019 (COVID-19) are poorly understood. METHODS: We performed a prospective, multicenter, cross-sectional study of hospitalized children who met the Centers for Disease Control and Prevention case definition for MIS-C (n = 118), acute COVID-19 (n = 88), or contemporaneous healthy controls (n = 24). We measured severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike receptor-binding domain (RBD) immunoglobulin G (IgG) titers and cytokine concentrations in patients and performed multivariable analysis to determine cytokine signatures associated with MIS-C. We also measured nucleocapsid IgG and convalescent RBD IgG in subsets of patients. RESULTS: Children with MIS-C had significantly higher SARS-CoV-2 RBD IgG than children with acute COVID-19 (median, 2783 vs 146; P < .001), and titers correlated with nucleocapsid IgG. For patients with MIS-C, RBD IgG titers declined in convalescence (median, 2783 vs 1135; P = .010) in contrast to patients with COVID-19 (median, 146 vs 4795; P < .001). MIS-C was characterized by transient acute proinflammatory hypercytokinemia, including elevated levels of interleukin (IL) 6, IL-10, IL-17A, and interferon gamma (IFN-γ). Elevation of at least 3 of these cytokines was associated with significantly increased prevalence of prolonged hospitalization ≥8 days (prevalence ratio, 3.29 [95% CI, 1.17-9.23]). CONCLUSIONS: MIS-C was associated with high titers of SARS-CoV-2 RBD IgG antibodies and acute hypercytokinemia with IL-6, IL-10, IL-17A, and IFN-γ.

Retropharyngeal Edema and Neck Pain in Multisystem Inflammatory Syndrome in Children (MIS-c).

We defined the prevalence of neck pain, trismus, or dysphagia (28.4%) and retropharyngeal edema (2.9%) among 137 patients with multisystem inflammatory syndrome in children (MIS-c). Retropharyngeal edema or phlegmon has been documented radiologically in at least 9 children. Symptoms of neck inflammation are common in MIS-c.

Differential type I interferon response and primary airway neutrophil extracellular trap release in children with acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a heterogeneous condition characterized by the recruitment of large numbers of neutrophils into the lungs. Neutrophils isolated from the blood of adults with ARDS have elevated expression of interferon (IFN) stimulated genes (ISGs) associated with decreased capacity of neutrophils to kill Staphylococcus aureus and worse clinical outcomes. Neutrophil extracellular traps (NETs) are elevated in adults with ARDS. Whether pediatric ARDS (PARDS) is similarly associated with altered neutrophil expression of ISGs and neutrophil extracellular trap release is not known. Tracheal aspirate fluid and cells were collected within 72 h from seventy-seven intubated children. Primary airway neutrophils were analyzed for differential ISG expression by PCR, STAT1 phosphorylation and markers of degranulation and activation by flow cytometry. Airway fluid was analyzed for the release of NETs by myeloperoxidase-DNA complexes using an ELISA. Higher STAT1 phosphorylation, markers of neutrophil degranulation, activation and NET release were found in children with versus without PARDS. Higher NETs were detected in the airways of children with ventilator-free days less than 20 days. Increased airway cell IFN signaling, neutrophil activation, and NET production is associated with PARDS. Higher levels of airway NETs are associated with fewer ventilator-free days.

Behaviorally based adherence program for pediatric patients treated with positive airway pressure.

OBJECTIVES: Positive Airway Pressure (PAP) devices are being increasingly used in pediatric populations for problems including Obstructive Sleep Apnea. There is limited literature regarding pediatric adherence with PAP treatment or successful interventions that improve adherence. This paper describes a clinical program for pediatric PAP users which was designed to improve adherence of patients prescribed PAP therapy and involves intensive assessment and behavioral intervention. METHOD: The design and implementation of the program is described, including the purpose, goals, programmatic structure, clinical content, type and training of personnel, strengths and limitations and financial concerns as well as the challenges with the development and application of the program's protocol. RESULTS: Preliminary outcome data show short-term improvements in consistent usage for many of the patients. CONCLUSIONS: The program shows some promise and provides a framework for future program development and research.