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.

Ophthalmia nodosa secondary to intraocular, white-marked tussock caterpillar setae (Orgyia leucostigma) in a 15-year-old.

A 15-year-old female presented to the emergency department with a 1-day history of pain and swelling of her right eye following ocular contact with a caterpillar. Caterpillars of the white-marked tussock moth and other related species possess hairlike structures called setae, with angled barbs along their length, allowing them to travel linearly upon penetration of an enemy, resisting backward movement and becoming very difficult to extract once imbedded. When these fine, pointed hairs contact the surface of the eye, they can easily migrate in, eliciting movement of the globe, blinking, and rubbing of the eye in an attempt to remove the offending agent, potentially leading to ophthalmia nodosa. One of the most important aspects of ophthalmia nodosa diagnosis is a thorough history and prompt slit-lamp examination to identify the presence of foreign bodies and where they are located; this will help guide clinical management decisions. This case demonstrates that, depending on the number and location, more than one attempt may be required to remove all of the barbed setae. If ophthalmia nodosa is suspected, it is important to promptly refer to ophthalmology for a thorough eye exam, keep the eye clean, prescribe prophylactic topical antibiotics and/or steroids to reduce the potential for infection and inflammation, and emphasize the importance of keeping the eye protected during the healing process with an eye shield.

Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training.

PURPOSE: To describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees. METHODS: We conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training. RESULTS: Forty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited "time" (55%, n = 136/243) most frequently as a barrier. CONCLUSIONS: Our needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.

Persistent Atraumatic Knee Pain in a Teenage Female with Bony Protuberance Secondary to Hook-Shaped Osteochrondroma.

A 13-year-old female presented at her pediatrician's office with a complaint of sharp, intermittent, right-sided knee pain that had been present for the previous three days without any known trauma and no association with activity. Her medical history was significant for fractures, and on physical exam, there was a hard mass palpated on the medial aspect of her distal thigh that was nontender, nonmobile, and without overlying skin changes. The plain radiograph findings were consistent with a hook-shaped osteochondroma of the right medial distal metaphysis. Orthopedics recommended conservative management with continued ibuprofen for pain and six-week follow-up with repeat radiograph to evaluate for progression. The follow-up radiograph showed no interval growth. However, due to continued pain, the patient had surgical excision of the osteochondroma six months after initial presentation, allowing her to finish her current soccer season. The surgery was successful, and the patient did well after operation with no residual pain.

Adult Caregiver Influenza Vaccination Through Administration in Pediatric Outpatient Clinics: A Cocooning Healthcare Improvement Project.

BACKGROUND: Pediatric exposure to influenza-infected adult caregivers (AC) is a significant risk factor for developing influenza. Poor access to vaccines contributes to low adult vaccination rates. We offered adult vaccination at regularly scheduled pediatric office visits and examined barriers to improve future vaccination rates. METHODS: Via a retrospective chart review, we identified ACs who received an influenza vaccination at 1 of 3 pediatric clinics within an academic center from August 2015 to May 2016. We screened for demographics of ACs and their children. Rates of AC vaccination and AC refusal were not measured. RESULTS: A total of 297 ACs representing 518 children received their influenza vaccine at their child's pediatric office. The mean age of ACs was 35.9 years (range, 22-70 years) and 68.5% were mothers. Most ACs (n = 294, 99%) receiving the vaccine had private insurance. Almost all ACs received their vaccination on the day of the child's visit (n = 250, 84%). A total of 49.6% of AC's children had high-risk illnesses. Parents of children with Medicaid were under-represented because of high parental copays (n = 3, 1%). The highest clinic vaccine participation was noted at the clinics with lowest Medicaid populations. CONCLUSIONS: ACs readily accepted influenza vaccination at their child's pediatric primary care office. Increased vaccination acceptance occurred when ACs were female, had private insurance, if their child had a chronic illness and if the vaccination was offered the same day as their child's appointment. Likely reason for low acceptance in ACs with Medicaid insurance is high cost; thus, staff, well-aware of Medicaid's nonreimbursement, likely offered the vaccine less to these parents.

10-Year-Old Female with Acute Abdominal Pain with Pancreatic Mass.

A previously healthy 10-year-old female presented to a local emergency department following three days of nausea and vomiting diagnosed with a solid pseudopapillary tumor. Solid pseudopapillary neoplasms are a rare form of pancreatic cystic neoplasm that typically presents in young females in their 20-30s and are very rare in children. These neoplasms often present as an asymptomatic tumor found on incidental imaging. When symptomatic they most commonly present with abdominal pain and can also cause a palpable abdominal mass, weight loss, gastrointestinal obstruction, and nausea and vomiting. Timely diagnosis of this rare neoplasm is very important because complete resection of the tumor is the definitive treatment and leads to an excellent long-term survival.

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.

Elevated Alkaline Phosphatase in Children: An Algorithm to Determine When a "Wait and See" Approach is Optimal.

Due to the possibility of underlying hepatobiliaryor bone diseases, the diagnostic work up of a child with elevated alkaline phosphatase (AP) levels can be quite costly. In a significant proportion of these patients, elevated AP is benign, requiring no intervention: hence, known as transient hyperphosphatasemia (THP) of infants and children. A 27-month old previously healthy Caucasian female was found to have isolated elevation of AP four weeks after the initial symptoms of acute gastroenteritis. One month later, when seen in hepatobiliary clinic, signs and symptoms of gastrointestinal, hepatobiliary, or bone disease were absent and physical examination was normal. The diagnosis of THP was made, and, as anticipated, AP levels normalized after four months. Using this case as an example, we suggest an algorithm that can be utilized as a guide in a primary care setting to arrive at the diagnosis of THP and avoid further tests or referrals.

Bone marrow stem and progenitor cell contribution to neovasculogenesis is dependent on model system with SDF-1 as a permissive trigger.

Adult bone marrow (BM) contributes to neovascularization in some but not all settings, and reasons for these discordant results have remained unexplored. We conducted novel comparative studies in which multiple neovascularization models were established in single mice to reduce variations in experimental methodology. In different combinations, BM contribution was detected in ischemic retinas and, to a lesser extent, Lewis lung carcinoma cells, whereas B16 melanomas showed little to no BM contribution. Using this spectrum of BM contribution, we demonstrate the necessity for site-specific expression of stromal-derived factor-1alpha (SDF-1alpha) and its mobilizing effects on BM. Blocking SDF-1alpha activity with neutralizing antibodies abrogated BM-derived neovascularization in lung cancer and retinopathy. Furthermore, secondary transplantation of single hematopoietic stem cells (HSCs) showed that HSCs are a long-term source of neovasculogenesis and that CD133(+)CXCR4(+) myeloid progenitor cells directly participate in new blood vessel formation in response to SDF-1alpha. The varied BM contribution seen in different model systems is suggestive of redundant mechanisms governing postnatal neovasculogenesis and provides an explanation for contradictory results observed in the field.