Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management.

Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.

Understanding and identifying the needs of parent caregivers of children with hydrocephalus: a qualitative study.

OBJECTIVE: Hydrocephalus is inherently unpredictable. Most parents whose child is diagnosed with hydrocephalus do not anticipate the diagnosis, nor can anyone predict if or when a child's shunt will fail and require emergency surgery. Previous research has shown that children with hydrocephalus and their caregivers experience significant posttraumatic stress symptoms secondary to the diagnosis. This study aims to understand caregiver experiences and needs, identify gaps in resources/support, and determine opportunities to improve care. METHODS: Semistructured interviews were conducted with parent caregivers of children with hydrocephalus to learn about their experiences with the hydrocephalus diagnosis, hospitalizations, surgeries, coping and support, challenges of caring for a child with hydrocephalus, and logistics for a proposed support program. De-identified interviews were audio-recorded, transcribed, and analyzed for themes. RESULTS: Thematic saturation was reached after 17 interviews. Five major themes emerged: 1) coping with the diagnosis, 2) received support, 3) hydrocephalus management, 4) implications for intervention, and 5) psychosocial stressors for caregivers. A top priority was balanced, trustworthy information delivered with compassion and updated throughout the child's life. Caregivers described a variety of coping strategies, but a majority reported a need for support in processing complex emotions and dealing with the uncertainty of their child's hydrocephalus. Most agreed that having a caregiver support network, medical professionals available for referrals and questions, and referrals to support services and therapies would facilitate feeling supported and providing the best care for their children. CONCLUSIONS: Parent caregivers are critical to the health and well-being of children with hydrocephalus, and it is essential to understand their experiences to improve care. Providing well-defined information, psychosocial support, and resources will help to equip parent caregivers to be advocates for their children and to improve both the caregiver and the child's quality of life.

Management of partial Müllerian agenesis: staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification.

INTRODUCTION: The objectives of this video are to provide a brief overview of Müllerian agenesis, discuss a case of partial vaginal agenesis with a functional uterus, and present the steps of a staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification. METHODS: We give an overview of Mayer-Rokitansky-Küster-Hauser syndrome, and review its incidence, clinical presentation, diagnostic evaluation, and treatment options. We present the case of a 23-year-old woman with partial vaginal agenesis, and her clinical course through conservative management with hormonal suppression and dilator therapy leading up to urogynecological surgical treatment. We describe a staged surgical approach that highlights the value of cystoscopy and laparoscopy to better delineate our patient's anatomical variations. Additionally, a mini-laparotomy and placement of an intrauterine Malecot catheter allowed for the drainage of prominent hematometra, relief of menstrual outflow obstruction, and epithelialization of a tract between the uterus and the planned neovaginal space. Ultimately, a neovagina was created using a staged McIndoe technique, leading to utero-neovaginal unification and unobstructed menses. CONCLUSION: In conclusion, our approach should be considered a feasible option for anatomical restoration via the creation of a neovagina in patients with Müllerian anomalies, even in the presence of a functional uterus.

Utility of a Continuous External Tissue Expander in Complex Pediatric Wound Reconstruction.

Background: Soft tissue reconstruction following traumatic injury can be devastating. Reconstructive treatment modalities can prove to be complex. DermaClose (Synovis Micro Companies Alliance, Inc) is a relatively novel wound closure device that has gained popularity for continuous external tissue expansion (CETE). Methods: A single-institution case series of 3 traumatic pediatric soft tissue injuries in which DermaClose was used for soft tissue reconstruction as an alternative to free tissue transfer was presented. A review of the literature to identify similar reported cases was also conducted. Results: The authors report their success with the use of this continuous external tissue expander in the management of pediatric soft tissue injuries. Open tibial fractures were sustained by 2 patients, and 1 patient suffered an avulsion injury to the scalp; sequential DermaClose application was successfully utilized to achieve wound closure in all cases. Conclusions: The minimal amount of data currently available in the literature that document the use of this continuous external tissue expander in pediatric patients suggest that its safety and efficacy are inadequately investigated in this population. The cases included in this report suggest DermaClose may be an alternative to traditional methods for complex soft tissue closure in pediatric patients. For larger wounds, repeat applications with sequential closure should be expected and is described in an algorithm within this report.

Post-Traumatic Stress Symptoms in Caregivers and Children with Hydrocephalus.

OBJECTIVE: Hydrocephalus is a disorder of cerebrospinal fluid dynamics, traditionally treated by placement of a ventricular shunt. Shunts are effective but imperfect as they fail in an unpredictable pattern, and the patient's well-being is dependent on adequate shunt function. The omnipresent threat of shunt failure along with the potential need for invasive investigations can be stressful for patients and caregivers. Our objective was to measure post-traumatic stress symptoms (PTSS) in children with hydrocephalus and their caregivers. METHODS: A cross-sectional analysis of children with hydrocephalus and their caregivers was conducted. Caregivers completed a measure of their own PTSS (the Post-Traumatic Stress Disorders Checklist for the Diagnostic and Statistical Manual of Mental Disorders-V) and resilience (the Connor Davidson Resilience Scale). Pediatric patients rated their own PTSS and resilience using the Acute Stress Checklist for Kids and Connor Davidson Resilience Scale. RESULTS: Ninety-one caregivers completed the Post-Traumatic Stress Disorders Checklist for the Diagnostic and Statistical Manual of Mental Disorders-V. Mean score was 17.0 (standard deviation 15.7; median 13.0). Fourteen percent scored above 33, the threshold suggestive of a preliminary diagnosis of post-traumatic stress disorder. There was a statistically significant association between caregiver post-traumatic stress and marital status, child's race, and caregiver education. More than half (52%) of caregivers reported their child's hydrocephalus as the most significant source of their PTSS. Children did not have markedly elevated levels of PTSS. Forty-one percent of caregivers and 60% of children scored in the lowest resilience quartile compared with the general population. CONCLUSIONS: Results from this study suggest that post-traumatic stress affects caregivers with hydrocephalus, yet levels of resilience for caregivers and pediatric patients are low.

Hydrocephalus-related quality of life as assessed by children and their caregivers.

OBJECTIVE: Hydrocephalus is a chronic medical condition that has a significant impact on children and their caregivers. The objective of this study was to measure the quality of life (QOL) of children with hydrocephalus, as assessed by both caregivers and patients. METHODS: Pediatric patients with hydrocephalus and their caregivers were enrolled during routine neurosurgery clinic visits. The Hydrocephalus Outcomes Questionnaire (HOQ), a report of hydrocephalus-related QOL, was administered to both children with hydrocephalus (self-report) and their caregivers (proxy report about the child). Patients with hydrocephalus also completed measures of anxiety, depression, fatigue, traumatic stress, and headache. Caregivers completed a proxy report of child traumatic stress and a measure of caregiver burden. Demographic information was collected from administration of the Psychosocial Assessment Tool (version 2.0) and from the medical record. Child and caregiver HOQ scores were analyzed and correlated with clinical, demographic, and psychological variables. RESULTS: The mean overall HOQ score (parent assessment of child QOL) was 0.68. HOQ Physical Health, Social-Emotional Health, and Cognitive Health subscore averages were 0.69, 0.73, and 0.54, respectively. The mean overall child self-assessment (cHOQ) score was 0.77, with cHOQ Physical Health, Social-Emotional Health, and Cognitive Health subscore means of 0.84, 0.79, and 0.66, respectively. Thirty-nine dyads were analyzed, in which both a child with hydrocephalus and his or her caregiver completed the cHOQ and HOQ. There was a positive correlation between parent and child scores (p < 0.004 for all subscores). Child scores were consistently higher than parent scores. Variables that showed association with caregiver-assessed QOL in at least one domain included child age, etiology of hydrocephalus, and history of endoscopic third ventriculostomy. There was a significant negative relationship (rho -0.48 to -0.60) between child-reported cHOQ score and child-reported measures of posttraumatic stress, anxiety, depression, and fatigue. There was a similar significant relationship between caregiver report of child's QOL (HOQ) and caregiver assessment of the child's posttraumatic stress symptoms as well as their assessment of burden of care (rho = -0.59 and rho = -0.51, respectively). No relationship between parent-reported HOQ and child-reported psychosocial factors was significant. No clinical or demographic variables were associated with child self-assessed cHOQ. CONCLUSIONS: Pediatric patients with hydrocephalus consistently rate their own QOL higher than their caregivers do. Psychological factors such as anxiety and posttraumatic stress may be associated with lower QOL. These findings warrant further exploration.

Anxiety, depression, fatigue, and headache burden in the pediatric hydrocephalus population.

OBJECTIVE: Childhood hydrocephalus is a common chronic medical condition. However, little is known about the burden of headache and psychological comorbidities in children living with hydrocephalus. The purpose of this study was to determine the prevalence and severity of these conditions among the pediatric hydrocephalus population. METHODS: During routine neurosurgery clinic visits from July 2017 to February 2018, the authors administered four surveys to children ages 7 years and older: Pediatric Migraine Disability Assessment (PedMIDAS), Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, and PROMIS Fatigue. The PedMIDAS is an assessment of headache disability in pediatric and adolescent patients. The PROMIS measures are pediatric self-reported instruments to assess social and emotional health. PROMIS measures utilize T-scores (mean 50, SD 10) to compare anxiety, depression, and fatigue in specific populations to those in the US general population. Clinical and demographic data were collected from the medical record (hydrocephalus etiology, shunt infection, race, etc.) and tested for associations with survey measure scores. RESULTS: Forty children completed the PedMIDAS. Ten percent of them were in the severe headache range, 5% were in the moderate range, and 5% were in the mild range. There was a statistically significant association between undergoing a cluster of shunt operations and headache burden (p = 0.003).Forty children completed all three PROMIS measures. The mean anxiety score was 45.8 (SD 11.7), and 2.5% of children scored in the severe anxiety range, 17.5% in the moderate range, and 20% in the mild range. The mean depression score was 42.7 (SD 10.0), with 2.5% of children scoring in the severe depression range, 5% in the moderate range, and 12.5% in the mild range. The mean fatigue score was 45.1 (SD 16.4), with 15% percent of children scoring in the severe fatigue range, 10% in the moderate range, and 7.5% in the mild range. There were no statistically significant associations between child anxiety, depression, or fatigue and clinical or demographic variables. CONCLUSIONS: Children with hydrocephalus have an average burden of headache, anxiety, depression, and fatigue as compared to the general population overall. Having a cluster of shunt operations correlates with a higher headache burden, but no clinical or demographic variable is associated with anxiety, depression, or fatigue.

Os Styloideum Resection Complicated by Severe Contact Dermatitis to 2-Octyl Cyanoacrylate: A Case Study.

Os styloideum is an accessory wrist bone at the base of the second and third metacarpals. Similar to metacarpal bossing, chronic pain secondary to the development of osteoarthritis and tendon irritation is common. Conservative management consists of splinting and steroid injections, with surgical resection being the definitive treatment. 2-Octyl cyanoacrylate adhesive glue is commonly used to close these and other types of wounds. PURPOSE: We report the case of a 29-year-old man who developed severe dermatitis following surgical removal of a right dorsal hand mass at the base of the third metacarpal, which had been slowly enlarging and causing pain for 18 months. METHODS: After unsuccessful conservative management, the mass was resected and the incision was closed with buried monofilament suture and 2-octyl cyanoacrylate skin glue. Upon splint removal due to pain, 6 days postoperatively, severe contact dermatitis resulting in scattered partial- and full-thickness skin necrosis was observed. Local wound care, systemic corticosteroids, and a secondary surgical closure were required for resolution of the skin breakdown. CONCLUSION: This case demonstrates 2 uncommon occurrences: a rare hand mass and severe contact dermatitis to 2-octyl cyanoacrylate with resultant tissue necrosis. Mass resection is commonly reserved for symptomatic os styloideum. Caution should be used when applying 2-octyl cyanoacrylate under a splint. Removal of glue and steroids provides effective treatment for severe contact dermatitis, but full-thickness injuries may require debridement and secondary closure.