Yana Puckett

Synchronous Uterine Metastases from Breast Cancer: Case Study and Literature Review

Breast cancer rarely metastasizes to the uterus. Here, we report two breast cancer patients with synchronous metastases to the uterus. Case 1 highlights a 46-year-old female with invasive ductal carcinoma who presented with a breast mass and was found to have uterine enlargement on positron emission tomography (PET) scan. Biopsy revealed a metastatic 4 mm focus of breast cancer in the background of endometrial hyperplasia. Case 2 reports a 62-year-old postmenopausal female diagnosed with lobular carcinoma of the breast following an abnormal screening mammogram. A routine pap smear necessitated further workup, revealing simultaneous endometrial and cervical metastasis. Both patients did not have any gynecologic symptoms and presented a diagnostic challenge.

Mediastinal Granular Cell Tumor in a 16-Year-Old Boy: A Surgical and Pathologic Perspective.

Granular cell tumor is a benign tumor of likely neural or neuroectodermal origin that occurs most commonly in the subcutaneous tissues of the trunk, breast, and extremities of adults. Congenital gingival lesions comprise the majority of the pediatric granular cell tumors. Granular cell tumors are generally small and asymptomatic, and while 1 in 10 patients has multiple tumors, recurrence and malignancy are very rare. Mediastinal granular cell tumors have been reported, most occurring in young adult or middle-aged women. We present a case of a 16-year-old asymptomatic boy with a large mediastinal granular cell tumor incidentally identified after a motor vehicle accident, and we review the intraoperative, microscopic, and ultrastructural features of this tumor. Both the patients age and anatomical location are unusual for this tumor, which presented technical and diagnostic challenges to the patient care team.

Imaging before transfer to designated pediatric trauma centers exposes children to excess radiation.

BACKGROUND Pediatric trauma patients transferred to pediatric trauma centers (PTCs) often have imaging at the originating hospital (OH). The increased use of computed tomography (CT) raises concerns about malignancy risk from ionizing radiation leading many PTCs to adopt radiation dose reduction strategies. We hypothesized that pediatric trauma patients are exposed to excess radiation from imaging before transfer. METHODS A retrospective review of 1,383 scans was performed on all trauma patients with CT imaging before transfer to our Level I PTC from 2010 to 2014. Demographics, type of imaging, necessity for repeat imaging, appropriateness of imaging, and radiation dose delivered were recorded. Comparative radiation dosing was calculated using the dose-length product (DLP [expressed in mGy-cm]). All CT scans except for CT of the abdomen and pelvis and CT of the head were excluded for complete DLP data issues. Scans were considered clinically appropriate if they met Advanced Trauma Life Support (ATLS) recommendations (ATLS+) and not indicated if they did not meet ATLS criteria (ATLS−). Some scans were repeated because of technical issues. Median &Dgr;DLP represents the difference in dose patients received at OH versus at PTC. RESULTS A total of 673 patients were analyzed. Average age was 11 years, and 65.4% were male. Mean DLP at PTC was 54% lower for all analyzed scans compared with OH (p < 0.0001). DLP at PTC was 51% lower for CT of the abdomen and pelvis and 62% lower for CT of the head. Children received excess dose of 578.62 mGy-cm for scans at OH that were unnecessary. For ATLS+ imaging, children received a median excess of 444.42 mGy-cm of radiation at OH than they would have received had the scans been performed at PTCs using pediatric radiation reduction strategies. CONCLUSION Pediatric trauma imaging performed at transferring institutions often does not adhere to ATLS recommendations and exceeds required ionizing radiation dosages. This study further confirms ATLS recommendations supporting prompt patient transfer without delay for imaging. LEVEL OF EVIDENCE Therapeutic study, level IV.

Socioeconomic Factors Impact Inpatient Mortality in Pediatric Lymphoma Patients.

Purpose: Our objective was to determine the risk factors for inpatient mortality of pediatric patients diagnosed with lymphoma through the utilization of a large national pediatric database. Methods: This cross-sectional study uses data from the Healthcare Cost and Utilization Project Kids Inpatient Database (HCUP KID) for the year of 2012 to estimate the risk factors for inpatient mortality for pediatric patients diagnosed with lymphoma. All patients diagnosed with lymphoma between the ages of one and 18 years were included. Chi-square test was used to analyze categorical variables. Independent t-test was used to analyze continuous variables. Results: A total of 2,908 study subjects with lymphoma were analyzed. Of those, 56.1% were male and the average age was three years old. Total inpatient mortality was 1.2% or 34 patients. We found that patients with four or more chronic conditions were much more likely to die while hospitalized (p < 0.0001). In addition, we also saw that patients with median household incomes below

Risk Factors for Inpatient Hospital Admission in Pediatric Burn Patients

47,999 dollars (p = 0.05) having a need for a major procedure (p = 0.008) were associated with inpatient mortality. Congestive heart failure, renal failure, coagulopathy, metastatic disease, and electrolyte abnormalities were all found to be associated with inpatient mortality. Conclusions: Pediatric lymphoma mortality in children is not only influenced by their medical condition but also by their socioeconomic condition as well.

Safest Time to Resume Oral Anticoagulation in Patients with Traumatic Brain Injury

Purpose Our objective was to determine the risk factors for inpatient admission of pediatric burn patients. Materials & methods This cross-sectional study uses data from the Healthcare Cost and Utilization Project Kids Inpatient Database (HCUP KID) for the years of 2003, 2006, 2009, and 2012 to estimate the risk factors for inpatient admission for pediatric patients who sustained a burn injury. Patients who sustained a burn between the ages of 1 and 18 years were included. Results A total of 43,453 patients met inclusion criteria. Of those, 42.3% were Caucasian, 20.1% were African American, and 19.3% were Hispanic. Males comprised 63.5% of the studied population. The month of July was associated with a 31.8% increased chance (p=.011) of being admitted to hospital for a pediatric burn. It was found that patients being admitted had a 32.2% increased chance (p=.002) of a fluid and electrolyte abnormality and a 61.0% increased chance (p=.027) of drug abuse. Conclusions Pediatric burn patients are more likely to be admitted to the hospital having a fluid and electrolyte abnormality, having a drug abuse status, and/or during the month of July.

Deployment of a Resuscitative Endovascular Balloon Occlusion of the Aorta Device in a Case of Gunshot Wound Injury to a Horseshoe Kidney

Objective: There is no standard protocol to guide the optimal time to resume anti-clotting agents after traumatic brain injury (TBI) in patients with a continued indication for anticoagulation/antiplatelet therapy (AAT). This study develops baseline data supporting a future prospective cohort study. We predict that there will be significantly decreased adverse events when AAT is started on or after Day 7. Methods: A retrospective chart review of 256 patients was performed. Patients admitted to a level I trauma center in West Texas between January 1, 2009, and December 31, 2012, on anti-clotting agents (specifically acetylsalicylic acid, coumadin, and/or clopidogrel) and who suffered a TBI were included. Patient metrics included admission coagulation studies, type of TBI and treatment, and time to continuation of AAT. Outcomes were assessed using follow-up appointment data. The primary outcome was death (mortality). Secondary outcomes included myocardial infarction, stroke, re-bleed, venous thromboembolism, and pneumonia. Results: A total of 256 patients met the inclusion criteria. However, only 85 patients on AAT presented for the six-month follow-up. Time to AAT resumption varied from immediate to 31 days. Out of the 85 patients, 32 patients never resumed AAT, 32 patients were restarted on AAT medication in less than seven days, 10 patients restarted medication between seven and 14 days, and 11 patients restarted AAT in more than 14 days. Adverse events occurred most infrequently in the AAT group resuming therapy between seven and 14 days (10%). Adverse events were most prevalent in the AAT group that never resumed therapy (68.8%). Conclusion: While most studies suggest that the safest time for resuming AAT lies between three and 10 days, our study revealed that adverse events were minimized in patients on AAT between seven and 9.5 days.

Porcine Urinary Bladder Matrix for Management of Infected Radiation Mastectomy Wound

A horseshoe kidney (HSK) is a urological malformation that is typically found incidentally after a traumatic injury due to its asymptomatic nature. We present a 25-year-old male with multiorgan injuries secondary to blunt abdominal trauma caused by a gunshot wound. We report the courses of action taken that led to the identification of the HSK and other associated intra-abdominal injuries and the subsequent surgical management. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an improving minimally invasive technique that was used to control hemorrhage in the early preoperative stages and during surgical repair of the injuries. Multiorgan injuries that involve an HSK are uncommon. Our interest in the case relies on the rarity and unique aspects of the injuries and the recovery of the patient following the use of REBOA.

Utility of hospital admission for pediatric intussusceptions

We present a case report on the successful healing of a Pseudomonas infection wound in a 52-year-old female with morbid obesity, noninsulin dependent diabetes mellitus and a history of tobacco use, who presented with Stage IIIA (T3, N2, Mo) infiltrating ductal carcinoma. The patient received neoadjuvant chemotherapy prior to her bilateral skin-sparing total mastectomies with right axillary sentinel lymphadenectomy. She also had staged reconstruction with temporary breast implants and plans for deep inferior epigastric perforator flaps. Two months after chest wall and regional nodal radiation therapy, she developed a marked soft tissue reaction to radiation. She underwent over 10 right chest wall open wound radical debridements resulting in a tissue defect of 25 cm in length, by 20 cm in width, by 10 cm in depth. Despite surgical debridement, intravenous antibiotics, hyperbaric oxygen therapy, colistin spray therapy, and heat lamp therapy, the infection failed to resolve and the wound failed to heal. She was left with an open wound that was extremely painful and required chronic pain management with opioids. The patient later was found to have developed a multidrug-resistant Pseudomonas infection in her wound. However, the experimental placement of a porcine bladder matrix (ACell©, Inc., Columbia, MD) on the wound resulted in the complete relief of pain just three days after the application of the product. After two weekly applications of ACell©, her infection completely resolved and she was beginning to grow islands of new epidermis over her non-healing mastectomy wound.

Pediatric Trauma Transfer Imaging Inefficiencies—Opportunities for Improvement with Cloud Technology

PurposeThe standard practice in pediatric patients diagnosed with intussusception has been reduction via enema and admission for a period of nil per os and observation. Little data exists to support this practice. The objective of this study was to examine whether post-reduction admission to hospital is required.MethodsA retrospective chart review was performed onxa0all patients aged 0–18xa0years old with intussusception over a span of 20xa0years. Study included children treated for intussusception on first encounter with enema and subsequently admitted for observation. Study excluded those readmitted for recurrence after 48xa0h, patients whose intussusception did not reduce on first try, those lost to follow-up, and those who went to the operating room. Early recurrence was defined as recurrence within 48xa0h post-reduction.ResultsOut of 171 patients admitted, only one experienced an early recurrence (0.6xa0%). Median length of stay for all patients was 2xa0days. Average cost incurredxa0per day forxa0intussusceptionxa0admission was