Bottle mix-up: Ethanol intoxication in an infant.

Alcohol intoxication is a common ingestion in pediatrics with close to 10,000 reports to poison control centers annually. Hypoglycemia, neurological depression (ataxia, coma, nystagmus, etc.) and unstable vitals (hypothermia, hypotension, bradycardia, and respiratory depression) are common presentations. The patient is a 3 month old female who was brought into the Emergency Department (ED) for one day of decreased oral intake and inconsolability. Vital signs were reassuring. Physical exam revealed gaze preference to the right with inability to look left, dysconjugate gaze, and hypotonia. Work-up including CT of the head, and urinalysis was unremarkable. Urine drug screen was found to be positive for ethanol with follow up serum ethanol at 162 mg/dL. With conservative management the patient returned to her baseline. On follow-up with her pediatrician, it was elicited that the mother inadvertently used a water bottle of vodka to mix the patient's formula. This case adds to the paucity of literature of abnormal presentations of alcohol intoxication in an infant.

Endovascular Embolization of a Perforated Deep Femoral Artery in a 15-Year-Old Boy.

Trauma patients who are hemodynamically unstable or have certain signs of vascular injury should have immediate surgical exploration. For less severe signs of vascular injury, current literature states that endovascular intervention is optimal. This case presents the opportunity to review how signs of vascular injury were considered along with other diagnostic tools to inform decision-making after a penetrating stab wound injury to an extremity.  A 15-year-old male presented to the emergency department (ED) as a trauma activation after being stabbed in the left thigh. The patient had an approximately 5 cm long laceration over the lateral superior aspect of his left thigh with visible subcutaneous tissue and biceps femoris muscle upon probing. He had an initial blood pressure of 101/61 mm Hg. Shortly after the tourniquet was removed, the patient developed brisk bleeding from the wound and his blood pressure decreased to 88/55 mm Hg. He was taken expediently to computed tomography (CT) for an angiogram of the lower extremity which showed active bleeding from a posterior peripheral branch arising from the deep femoral artery in the posterolateral thigh. Interventional radiology performed intravascular embolization, and hemostasis was achieved. The patient was admitted for observation and then discharged 17 hours after admission without ambulatory difficulty. We present a case of penetrating extremity trauma (PET) where the patient had a presentation with mixed hard signs and soft signs of vascular injury. The patient responded well to endovascular embolization. Early detection and intervention in PET are critical in minimizing blood loss and ischemia to distal structures. While following professional organization guidelines can help guide care, a collaborative approach by multiple specialty care teams is critical in providing optimal care in PET.

Use of Three-Dimensional Imaging to Assess the Effectiveness of Volume as a Critical Variable in Breast Implant Selection.

BACKGROUND: In breast augmentation, breast base diameter has been recognized as an important variable in implant selection. However, breast implant volume also has a tremendous impact on the final result. Previous methods of preoperative volume determination have been limited to external devices in a bra. Computer-based three-dimensional simulation technology now allows the physician to effectively communicate with the patient preoperatively regarding volume. METHODS: A cohort of 40 consecutive patients underwent routine breast augmentation with either anatomically shaped or round implants. Five methods of preoperative volume determination including the Crisalix three-dimensional computer imaging system (Crisalix Virtual Aesthetics, Lausanne, Switzerland), along with an associated virtual reality tool, were used to assess the preoperative desires of the patients. A postoperative questionnaire was used to assess patient satisfaction with each volume determination method. RESULTS: Of the 40 patients, 100 percent were satisfied with their result; however, given the opportunity, 12 percent would have chosen a larger implant. The virtual reality tool and external sizers were shown to be the most effective in choosing an implant. The virtual reality tool was judged to be very helpful (62 percent), very accurate (78 percent), and important (88 percent) in helping patients choose their desired implant size. CONCLUSION: Prioritizing volume as an implant selection variable in breast augmentation results in a very high rate of patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sociodemographic Predictors of Patient Age at Time of Cleft Lip and Palate Repair.

OBJECTIVE: To identify the impact of sociodemographic and health variables on the age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation. DESIGN: A retrospective, noninterventional quality assessment, and quality improvement study was designed. SETTING: This institutional study was performed at Michigan Medicine in Ann Arbor, MI. PATIENTS: All patients born between 2011 and 2014 who received surgical cleft repair, excluded those who were adopted (n = 165). MAIN OUTCOME MEASURE: The age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation. RESULTS: Cleft lip repair was performed significantly later for patients identifying as Asian (18 weeks, P = .01), patients with Child Protective Services contact (19 weeks, P = .01), patients with a significant comorbidity (14 weeks, P = .02), and patients who underwent preliminary lip adhesion surgery (19 weeks, P < .01). Cleft palate repair was performed significantly later for patients identifying racially as Asian (19 weeks, P = .03) and other (22 weeks, P = .03). Preliminary speech and language evaluation were performed significantly later for patients identifying as black (55 weeks, P = .03) and patients diagnosed with an isolated cleft lip (71 weeks, P < .01). CONCLUSIONS: Timing of cleft lip, cleft palate repair, and primary speech and language evaluation are subject to variation which may be predicted by clinically accessible factors. By identifying race, Child Protective Services contact, and care variables as significant predictors of increased patient age at time of intervention, multidisciplinary cleft care teams can proactively allocate patient support resources.

Sociodemographic Predictors of Missed Appointments Among Patients With Cleft Lip and Palate.

OBJECTIVE: To identify disparities in compliance of and care for patients with cleft lip and/or palate (CL/P) by determining the impact of sociodemographic variables on the rate of missed appointments and Child Protective Services (CPS) involvement. DESIGN: A retrospective, noninterventional quality assessment and quality improvement study were designed. SETTING: This institutional study was performed at the University of Michigan in Ann Arbor, Michigan. PATIENTS: All patients born between January 1, 2011, and December 31, 2014, who underwent surgical CL/P repair, excluding those with fewer than 5 appointments (n = 178). MAIN OUTCOME MEASURE: The rate of missed appointments, calculated as the total number of no-show appointments divided by the total number of scheduled appointments. All appointments from CL/P diagnosis to data collection were considered, including those outside of plastic surgery. RESULTS: The average patient was 4.5 years of age and had 49 total scheduled appointments. The overall rate of missed appointments was 9.6%, with 66.8% of patients missing at least 1 scheduled visit. Patients who were black ( P = .04), not affiliated with a religion ( P = .01), Medicaid users ( P = .01), from an unstable social background ( P = .01), or received need-based financial assistance ( P = .00) were significantly more likely to miss appointments. Child Protective Services was involved with 3.9% of patients. CONCLUSIONS: Disparities exist in attendance rates among patients with CL/P, and at-risk patient populations have been identified. The allocation of cleft care resources must be efficiently planned in order to enhance the quality of care for at-risk individuals.