An Unusual Case of Extranodal Marginal Zone Lymphoma Mimicking Abdominal Cocoon Syndrome in an Adolescent Patient.

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is an indolent non-Hodgkin lymphoma rarely seen in pediatric patients. MALT lymphoma most commonly involves the gastrointestinal tract or peri-orbital tissues, potentially as sequela of chronic antigenic stimulation or immune dysregulation. Rare cases of MALT lymphoma arising from the gynecologic tract have been reported in older adult patients. We present the unique case of a 16-year-old postpubescent female with MALT lymphoma localized to the gynecologic tract, who initially presented with abdominal fullness, abnormal uterine bleeding, and obstructive acute kidney injury secondary to urinary outflow obstruction. Intraoperatively, dense fibrosis of the uterus and left fallopian tube was noted which mimicked abdominal cocoon syndrome. She was treated with 6 cycles of bendamustine and rituximab with complete anatomic and metabolic remission. In this report we highlight a very unusual presentation of a rare malignancy in the pediatric population as well as unique treatment considerations given this patient's young age and tumor location.

Gynecologic Care for Pediatric and Adolescent Patients Undergoing Hematopoietic Stem Cell Transplantation.

Hematopoietic stem cell transplantation is used to treat many chronic and acute malignant and nonmalignant conditions. We review hematopoietic stem cell transplantation and its effect on the gynecologic health of pediatric and adolescent patients, including pretransplantation evaluation, contraception, menstrual suppression, sexual health, fertility, primary ovarian insufficiency, and graft vs host disease. Comprehensive and team-based care provides optimal anticipatory counseling, evaluation, and management of acute and ongoing gynecologic issues.

Uterovaginal Anomalies: A Guide for the Generalist Obstetrician-Gynecologist.

Congenital gynecologic anomalies result from interruption of embryologic development of the female reproductive tract. The anomalies may be hymenal, vaginal, cervical, or uterine. The impact of these anomalies is variable: some are asymptomatic, incidental findings that require no intervention, others require simple surgical management, while some complex anomalies may require a multidisciplinary approach with extensive surgical expertise for optimal outcomes. Uterovaginal anomalies may occur in isolation or in association with other malformations, such as renal anomalies. The origin, presentation, evaluation and treatment of these conditions are reviewed here.

Content and Commentary: HPV Vaccine and YouTube.

STUDY OBJECTIVE: Human papillomavirus (HPV) vaccination has shown efficacy, however, many vaccine-eligible persons remain unvaccinated. YouTube is a popular video-sharing platform with several topics, including the HPV vaccine. Our purpose was to examine the tone of YouTube videos toward the HPV vaccine, accuracy of the information displayed, and content of commentary. DESIGN: In this observational study we investigated publicly available content regarding the HPV vaccine on the video-sharing Web site YouTube (www.youtube.com). Videos and comments were collected between June 22, 2014 and December 19, 2014. A total of 35 videos, with the 100 most recent comments for each video were collected and coded by a single researcher. A 25% subsample were coded by a second researcher to ensure inter-rater agreement of greater than 80%. SETTING, PARTICIPANTS, AND INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Videos were evaluated for 4 types of information: descriptive information, tone toward the vaccine (anti- or pro-vaccine), content, and commentary content, sorted according to 11 frequently identified themes. RESULTS: Most videos were negative in tone toward the vaccine. The tone of the video was not a predictor of video popularity. Pro-vaccine videos were 4 times more likely to report information accurately than anti-vaccine videos. Anti-vaccine videos were more likely to report information incorrectly and omit information. The most frequent commentary themes were concerning serious side effects, conspiracy theories, and vaccines generally being unhealthy. CONCLUSION: The Internet is an important resource for the general population; widely viewed YouTube videos contain erroneous and incomplete information. Anti-vaccine ideology is prevalent in video content and commentary.

Randomized Trial of Smartphone-Based Evaluation for an Obstetrics and Gynecology Clerkship.

OBJECTIVE: We hypothesized that compared to paper evaluations, a smartphone-based quick response (QR) evaluation tool would improve timeliness of feedback, enhance efficacy of giving and receiving feedback, and be as easy to use. DESIGN: We performed a randomized controlled trial of student and instructor experience with two evaluation tools in the OB/GYN clerkship at University of Washington School of Medicine (UWSOM). Sites were randomized to the QR or paper tool; students at QR sites received individualized QR codes at the beginning of the clerkship. Instructors and students completed postintervention surveys regarding the evaluation tool and associated feedback. We compared responses between groups using chi-squared tests. SETTING: Participating clerkship sites included primary, tertiary, private practice and institutional settings affiliated with the University of Washington in the Washington, Wyoming, Alaska, Montana and Idaho region. PARTICIPANTS: Of the 29 OB/GYN UWSOM clerkship sites, 18 agreed to participate and were randomized. Of 29 eligible instructors, 25 (86%) completed the survey, with n = 18 using QR and n = 7 using paper. Of 161 eligible students, 102 (63%) completed the survey, with n = 54 using QR and n = 48 using paper. RESULTS: Compared to those using paper evaluations, instructors using QR evaluations were significantly more likely to agree that the evaluation tool was easy to understand (100% QR vs 43% paper, p = 0.002), the tool was effective in providing feedback (78% QR vs 29% paper, p = 0.002), and they felt comfortable approaching students with the tool (89% QR vs 43% paper, p = 0.002). Compared to those using paper evaluations, students using QR evaluations were less likely to agree the tool was effective in eliciting feedback (QR 43% vs paper 55%, p = 0.042). CONCLUSION: Instructors found QR evaluations superior to paper evaluations for providing feedback to medical students, whereas students found QR evaluations less effective for feedback.

Bits and Pieces: A Crowd-Sourced Series of 54 Cases of Fractured Hormonal Implants.

STUDY OBJECTIVE: The fracture of hormonal implants, including Implanon, Nexplanon (both from Merck & Co, Inc), and histrelin acetate is rare. Our aim was to describe patient demographic characteristics, mechanisms, and consequences of fractured implants by surveying physicians' experience via listservs and social media. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We developed a Research Electronic Data Capture survey for physicians regarding their experience with implant fracture, including patient characteristics, mechanism of fracture, changes in menstrual bleeding patterns, time from insertion to fracture, and time from fracture to seeking care. We distributed the survey to providers in listservs for the North American Society for Pediatric and Adolescent Gynecology, the Family Planning Fellowship, the Ryan Program, and the Facebook Physician Moms Group and Facebook OB-GYN Mom Group. We performed descriptive analyses. RESULTS: We received 42 survey responses, representing 54 discrete implant fractures of which 70% (n=14) were Nexplanon, 26% (n=38) were Implanon, and 4% (n=2) were histrelin acetate. Mechanisms of implant fracture included patient manipulation (23%, n=12), unintentional trauma (11%, n=6), interpersonal violence (8%, n=4), lifting/carrying (6%, n=3), fracture with removal (6%, n=3), and unknown (47%, n=25). Bleeding pattern was not altered in 78% (n=42) of cases. Time interval between placement and fracture was less than 2 years for 63% (n=34) of cases. Thirty-nine percent (n=21) of patients presented for care more than 1 month from the time of fracture. CONCLUSION: Patients should be counseled about potential for hormonal implant fracture, advised against excessive manipulation of implants, and counseled to present for care immediately upon noticing an implant fracture. Surveying physicians through listervs and social media is an effective strategy to increase the reporting of rare complications and events.

Outcomes of Therapy for Vulvar Manifestation of Inflammatory Bowel Disease in Adolescents.

BACKGROUND: Vulvar manifestations of inflammatory bowel disease (IBD) are variable in presentation and challenging to treat. We describe vulvar manifestations and treatment response in female adolescents with IBD. CASES: We identified 6 patients with vulvar manifestations of IBD and documented treatments using retrospective chart review. Vulvar symptoms occurred without gastrointestinal (GI) symptoms in 1 patient. For the remaining 5 patients, 2 had GI symptoms before the onset of vulvar symptoms (mean time difference, 4.5 years); 3 patients had vulvar symptoms precede the onset of GI symptoms (mean time difference, 3.3 years). Vulvar IBD manifestations included pain, 100% (n = 6); enlargement, "fullness" or "edema" of the labia minora or majora, 66% (n = 4); ulcers, 50% (n = 3); and abscess, 50% (n = 3). Gynecologic procedures included biopsies, incision and drainages, and partial vulvectomies. All patients were treated with multiple systemic therapies. None of the patients responded to surgical or medical treatment alone; all had recalcitrant vulvar symptoms. SUMMARY AND CONCLUSION: Vulvar manifestations of IBD might precede GI symptoms in adolescents with IBD. Treatment is challenging and in this series, systemic therapies were the most successful in achieving symptomatic improvement.

Labor and delivery outcomes among young adolescents.

OBJECTIVE: We sought to determine whether young adolescents aged 11-14 years and teens aged 15-17 and 18-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20-24 years. STUDY DESIGN: We conducted a retrospective population-based cohort study using Washington State birth certificate data linked to hospital records from 1987 through 2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents aged 11-14 years, young teens aged 15-17 years, and older teens aged 18-19 years to young adults aged 20-24 years. The primary outcome was method of delivery. Secondary outcomes included postpartum hemorrhage, shoulder dystocia, third- and fourth-degree perineal lacerations, chorioamnionitis, prolonged maternal length of stay, gestational age at delivery, birthweight, respiratory distress syndrome, neonatal length of stay, and death. We used multivariate regression to assess associations between age and delivery outcomes. RESULTS: Young adolescents aged 11-14 years had a lower risk of cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.65-0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78-0.97) delivery compared to young adults aged 20-24 years. Compared to young adults, young adolescents had an increased risk of prolonged length of stay for both vaginal and cesarean delivery (RR, 1.34; 95% CI, 1.20-1.49, and RR, 1.71; 95% CI, 1.38-2.12, respectively), with no significant differences in indication for cesarean delivery or other measures of maternal morbidity. Young adolescents had an increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79-2.48), low and very low birthweight (RR, 2.08; 95% CI, 1.73-2.50, and RR, 3.25; 95% CI, 2.22-4.77, respectively), and infant death (RR, 3.90; 95% CI, 2.36-6.44) compared to young adults. CONCLUSION: Young adolescents have a decreased risk of cesarean and operative vaginal delivery compared to young adults; however, their neonates face higher risks of preterm delivery, low and very low birthweight, and death. This information can be used to inform clinical care for this population.

Long acting reversible contraception in adolescents with cardiovascular conditions.

STUDY OBJECTIVE: The purpose of this case series was to evaluate the efficacy and complication rate with use of long-acting reversible contraceptive (LARC) methods in adolescents with cardiovascular conditions. DESIGN AND PARTICIPANTS: We performed a retrospective chart review of adolescents age 22 or younger with congenital cardiac anomalies or major cardiovascular conditions who had a LARC device placed at Seattle Children's Hospital or University of Washington Medical Center between January 1, 2007 and March 1, 2012. MAIN OUTCOME MEASURES: Patient characteristics, medical conditions, indications, and complications including perforation, pregnancy, expulsion, and pelvic infection were collected and analyzed. RESULTS: Thirty adolescents with congenital cardiac anomalies or other cardiovascular conditions had a LARC device inserted during the study period. Mean age at placement was 17.7 years (range 12-22). Twelve patients (40%) had reported a previous pregnancy and 12 (40%) had never been sexually active at time of placement. Common primary and secondary indications were desired contraception (22 patients, 73%), desired menstrual suppression (15 subjects, 50%) and treatment of heavy menstrual bleeding (8 subjects, 27%). Twenty-nine patients had a structural cardiac anomaly. There were 27 levonorgestrel-releasing intrauterine devices (IUD), 1 copper IUD, and 3 etonogestrel implants placed. There were 2 confirmed IUD expulsions and 1 removal due to persistent irregular bleeding and cramping. There were no cases of pelvic inflammatory disease or pregnancies with LARC methods in place. Twenty-seven (90%) patients were continuing LARC at last follow-up. CONCLUSIONS: In this small case series of adolescents with cardiovascular conditions, LARC devices were effective at pregnancy prevention without serious complications.

Inadequate prenatal care and risk of preterm delivery among adolescents: a retrospective study over 10 years.

OBJECTIVE: The aim of this study was to determine whether inadequate prenatal care is associated with increased risk of preterm birth among adolescents. STUDY DESIGN: We selected a random sample of women under age 20 years with singleton pregnancies delivering in Washington State between 1995 and 2006. Multivariate logistic regression was used to assess the association between prenatal care adequacy (percent of expected visits attended, adjusted for gestational age) and preterm birth. RESULTS: Of 30,000 subjects, 27,107 (90%) had complete data. Women without prenatal care had more than 7-fold higher risk of preterm birth (n = 84 [24.1%]; adjusted odds ratio [aOR], 7.4), compared with those attending 75-100% of recommended visits (n = 346 [3.9%]). Women with less than 25%, 25-49%, or 50-74% of expected prenatal visits were at significantly increased risk of preterm birth; risk decreased linearly as prenatal care increased (n = 60 [9.5%], 132 (5.9%], 288 [5%]; and aOR, 2.5, 1.5, and 1.3, respectively). CONCLUSION: Inadequate prenatal care is strongly associated with preterm birth among adolescents.