Body Mass Index Increased at a Large Midwestern Children's Hospital During the COVID-19 Pandemic.

Background: The COVID-19 pandemic has presented a great challenge to children and their families with stay-at-home orders, school closures, decreased exercise opportunities, stress, and potential overeating with home confinement. Our study describes the body mass index (BMI) changes over an entire decade, including a year of the COVID-19 pandemic at a large children's hospital. Methods: With our retrospective observational study, data were extracted from Cincinnati Children's Hospital's Epic electronic medical record, a free-standing children's hospital with 670 inpatient beds and >1.2 million patient encounters per year. Children aged 19 years and under with at least one height and weight were included in the analysis. Results: In all, 2,344,391 encounters were analyzed with 712,945 visits in years 2018-2021. The prevalence of overweight/obesity was relatively stable with a gradual rise from 35% to 36.4% from 2011 to 2020. However, the year of the COVID-19 stay at home and restrictions (2020-2021) showed an increase in overweight/obesity to 39.7% (8.3% increase), with the greatest increase in those with Class 3 obesity from 3.0% to 3.8%. When viewing the change in BMI percentile during the pandemic year compared with the 2 years prior, there was a significantly increasing trend (p < 0.0001). Conclusions: Children attending a large children's hospital showed an increase in overweight/obesity during the COVID-19 pandemic. These data suggest greater efforts are needed to reverse the increase in weight status from the COVID-19 pandemic as obesity is a risk factor for poor outcomes with COVID-19.

Clival Paraganglioma, Case Report and Literature Review.

Paragangliomas are rare tumors that may present with cranial neuropathies when located along the skull base. Supratentorial paragangliomas are less likely to secrete catecholamines but should be worked up, nonetheless. We highlight a case of a female in her fourth decade found to have a petroclival lesion following initial presentation that included one month of tooth pain, dysphagia, diplopia, hoarseness and right hemifacial hypoesthesia. Magnetic resonance imaging of the brain demonstrated a T2 hyperintense lesion favored to be a petroclival meningioma. Pre-operative angiography demonstrated a hypervascular tumor. She underwent a combined presigmoid craniotomy with posterior petrosectomy performed by both neurosurgery and neuro-otology. Pathology demonstrated paraganglioma. She had small volume residual tumor and is planned for continued outpatient radiotherapy. Paragangliomas should be on the differential for skull base lesions. Management paradigm involves multidisciplinary care and a combination of surgical resection and post-operative radiation. In this paper, we discuss underlying pathophysiology as well as appropriate workup and management.

A 60-Year-Old Man With Dyspnea, Proximal Muscle Weakness, and Pulmonary Arterial Hypertension.

CASE PRESENTATION: A 60-year-old man with no significant medical history presented to the pulmonology clinic with 2 years of progressive weakness and shortness of breath. Showering and other activities of daily living caused him significant fatigue and dyspnea. He had a 20-pack-year smoking history, but no significant history of alcohol or illicit drug use. He did not take any prescribed or over-the-counter medications for chronic medical conditions and had never been on statin therapy. Vital signs were significant for an oxygen saturation of 91% on 4-L nasal cannula. He required up to 6 L of oxygen during a walk test. Physical examination showed mild inspiratory crackles in the lung bases, loud splitting of the second pulmonic valve (P2) with a right parasternal heave, and 2+ pitting edema in the lower extremities. There was muscle weakness, pain, and wasting of the proximal upper and lower extremities, particularly in his legs. He denied any joint pain, and there was no evidence of rash or dysphagia.

Clear-Cell Carcinoma of the Ovary with Bilateral Breast Metastases.

Ovarian clear-cell carcinoma is an uncommon subtype of epithelial ovarian carcinoma. It carries a generally poor prognosis because of its resistance to standard treatment and metastatic spread to vital organs. Metastasis to the breast is rare and bilateral breast metastasis is unreported. A 61-year-old white female with a 5-year status poststandard therapy for stage IC clear-cell ovarian carcinoma presented with widespread metastasis. Tissue analysis revealed ovarian cancer metastasis to the breasts bilaterally. Clinical awareness of this metastatic potential is important when staging and developing a treatment plan for patients with ovarian clear-cell cancer.

Ovarian Teratoid Carcinosarcoma Is an Aggressive Tumor of Probable Mullerian Derivation with a Carcinosarcomatous and Mixed Germ-Cell Morphology.

Ovarian carcinosarcoma is also referred to as malignant mixed Mullerian tumor (MMMT). It is a rare neoplasm, and although it represents less than 5% of malignant ovarian tumors, it remains generally well-known among clinicians and pathologists. Rarer yet is ovarian teratoid carcinosarcoma, defined as carcinosarcoma with the added feature of immature neuroectodermal tissue, with or without elements of primitive germ cell tumor. To our knowledge, six ovarian teratoid carcinosarcomas have been reported in the literature [Matsuura et al. J Obstet Gynaecol Res. 2010 Aug; 36(4): 907-11]. These tumors resemble nasopharyngeal tumors of the same name. We report a 55-year-old woman seen at Orlando Health's division of gynecological oncology whose pathology showed ovarian teratoid carcinosarcoma, and present what we believe to be a seventh report of this entity.

Remote Antimicrobial Stewardship in Community Hospitals.

Antimicrobial stewardship has become standard practice at university medical centers, but the practice is more difficult to implement in remote community hospitals that lack infectious diseases trained practitioners. Starting in 2011, six community hospitals within the Vidant Health system began an antimicrobial stewardship program utilizing pharmacists who reviewed charts remotely from Vidant Medical Center. Pharmacists made recommendations within the electronic medical record (EMR) to streamline, discontinue, or switch antimicrobial agents. Totals of charts reviewed, recommendations made, recommendations accepted, and categories of intervention were recorded. Linear regression was utilized to measure changes in antimicrobial use over time. For the four larger hospitals, recommendations for changes were made in an average of 45 charts per month per hospital and physician acceptance of the pharmacists' recommendations varied between 83% and 88%. There was no significant decrease in total antimicrobial use, but much of the use was outside of the stewardship program's review. Quinolone use decreased by more than 50% in two of the four larger hospitals. Remote antimicrobial stewardship utilizing an EMR is feasible in community hospitals and is generally received favorably by physicians. As more community hospitals adopt EMRs, there is an opportunity to expand antimicrobial stewardship beyond the academic medical center.

Pharmacokinetic analysis of piperacillin administered with tazobactam in critically ill, morbidly obese surgical patients.

STUDY OBJECTIVE: To evaluate the steady-state pharmacokinetic and pharmacodynamic parameters of piperacillin in morbidly obese, surgical intensive care patients. DESIGN: Open-label single-center prospective study. SETTING: Level I trauma center and university-affiliated teaching institution. PATIENTS: Nine morbidly obese (body mass index [BMI] 40.0 kg/m² or higher) hospitalized patients admitted to the trauma and surgical intensive care service who were treated with piperacillin-tazobactam between December 15, 2010, and April 18, 2012. INTERVENTION: Patients received intravenous piperacillin-tazobactam 4.5 g every 6 hours, administered as a 30-minute infusion. MEASUREMENTS AND MAIN RESULTS: Patients' blood samples were collected after the administration of the fourth, fifth, or sixth dose (i.e., at steady state). Serum piperacillin concentrations were determined by using a validated high-performance liquid chromatography assay; these concentrations were used to estimate pharmacokinetic parameters, and 5000-patient Monte Carlo simulations were performed. The probability of target attainment for 50% or higher of the dosing interval during which free (unbound) drug concentrations exceeded the minimum inhibitory concentration (%fT > MIC) of likely pathogens was calculated for piperacillin at various MICs. Patient demographic and clinical characteristics included a mean ± SD total body weight of 164 ± 50 kg, BMI of 57 ± 15.3 kg/m², and age 57 ± 11 years, and a median Acute Physiology and Chronic Health Evaluation II score of 22 (interquartile range 21-26). Compared with values previously reported in other populations, the volume of distribution was increased in the study patients, and total system clearance was decreased. The net result was a mean ± SD half-life of 3.7 ± 1.2 hours compared with ~1 hour reported in other populations. This contributed to an extended %fT > MIC for likely pathogens. Results from all nine patients showed %fT > MIC of 100% at the susceptibility breakpoint MIC of 16 mg/L and 85% or higher at an MIC of 32 mg/L. CONCLUSION: The pharmacokinetics of piperacillin is altered in morbidly obese, surgical intensive care patients. The use of standard-dosage piperacillin-tazobactam 4.5 g intravenously every 6 hours was shown to be an appropriate dosage for this study population.

Morbidity reduction in critically ill trauma patients through use of a computerized insulin infusion protocol: a preliminary study.

BACKGROUND: Recent data have demonstrated that intensive glycemic control during critical illness improves outcome. The purpose of our study was to evaluate the effect of a computerized hospital insulin protocol (CHIP) on glycemic control and outcome in critically ill trauma patients. METHODS: Two, 6-month cohorts were compared, one 6 months prior to chip implementation (pre-CHIP) and one from the 6-month period after implementation (post-CHIP), using finger stick blood glucose values and demographic, injury severity, and outcome variables for adult patients with intensive care unit length of stay (LOS) > or =72 hours. Infectious morbidity was based upon the National Trauma Registry of the American College of Surgeons definitions. Differences between cohorts were assessed using Student's t test and Fisher's exact test for continuous and categorical variables. RESULTS: The 129 pre- and 128 post-CHIP patients were well matched for demographics and injury severity. Significant reductions in mean finger stick blood glucose, rates of ventilator- associated pneumonia, central venous line infection, total infections, and all LOS categories were demonstrated in the post-CHIP cohort. However, mortality was significantly higher in the post-CHIP cohort. CONCLUSION: This preliminary study demonstrates significant morbidity and LOS reductions with the use of a CHIP, but significantly increased mortality. Further prospective studies are necessary to assess the effects of intensive glycemic control on outcome after injury, particularly in sub populations who might be adversely affected.