Focused Evaluation of Single-Unit Plasma Transfusions 0 in a Tertiary Care Academic Medical Center x AU SAINT LOUIS Thomas Fay, M.D., Daniela Hermelin, M.D., Douglas Blackall, M.D., M.RH. PAT H 0 LOGY uNIVERSITY. DEPARTMENT Department of Pathology, Saint Louis University School of Medicine SMWT LOI iVNPYIflJfl

INTRODUCTION 1 STUDY DESIGN a Blood utilization monitoring isa component of our institutional PBM program. Data for 2017 plasma transfusions were At Saint Louis University Hospital (SLUH), an academic, tertiary care facility, we extracted from our electronic health perform concurrent daily blood utilization reviews. record system During our audit, a surprising number of single-unit plasma transfusions were Inclusion Criteria identified in patients with normal coagulation values ‘All patients were adults (>18 years old) This study was performed to evaluate single-unit plasma transfusions in detail, Patients further subdivided into two groups; to identify opportunities to improve transfusion practice. patients with INR values s1.5 and patients with INR values >1.5 ‘Patients with INR values 1.5 were the RESULTS primary focus of this study •Additional study data collected included the transfusing clinical service, a post-transfusion . A total of 2,887 units of plasma were transfused in 2017. INR value obtained within 24 hours of criteria. 395(14%) were single-unit transfusions; 328(11%) met the inclusion transfusion (if available), and the probable 55 single-unit transfusions were associated with INR values 1.5. indication for transfusion S Surgical subspecialties and emergency medicine were the most common Exclusion Criteria: transfusing services. ‘Patients transfused with plasma in the A post-transfusion INR, when available, did not demonstrate a significant operating room or post-anesthesia care unit change from the pre-transfusion baseline. and The most common indications for transfusion included hypovolemia V MM pCONCLUSIONS it bleeding. See Results Diagram below S A daily audit revealed that single-unit plasma transfusion events are common. Surgical subspecialties and emergency medicine accounted for the majority of -V these transfusions. surgical .uhspariali.n i’d Total of 2,887 units 55 single-unit transfusion, em erg. n n edo ne These ikely represent inappropriate of plasma were associated vnth an wentsicd as the no,, fteç,r,t transfused INR value 1s on .rng prow en of vng!. transfusions and opportunities to improve FFPunns j practice institutionally. Though single-unit red cell and platelet transfusions represent desirabe practices, single-unit plasma transfusions are an ‘V -V undesirable quality improvement metric. 35 (14%) were 328(11%) Mail common indication, single-unit met the inclusion fortran, fusion included critnta hypovolemla and bleeding transfusions ______——______

Prevalence, Correlates, and Impact of Primary Immunodeficiency in Hospitalized Patients with Hematologic Malignancies

Sonia Mathew, MD; Kahee A. Mohammed, MD, MPH SAINT LOUIS UNIVERSITY Saint Louis University School of Medicine S BAC KG RU U N 0 RESULTS

patienl . eva!uatin the correlate, ot PlO among patienlsw ith - ruble i. We,ghted character; tics of pati,nls with Hful, stratitied 69 PiO, rlat:

- III 1546 081 OBJECTIVES - Other 81508 2) (05.41 - Wbinp 3 08 18.8.,.,, ci white 319279 (6491 2254 (22 II < 083 I lmnhiu,en gomoebidity med.. • This sludy aImed to describe (he prevalence oh PlO, socio-demographlc rIm hauser comw hidilv Irdm — .Le%P correlates of PlO, and ttne impacl of PID on short-term outcomes in hospitalized! 0 63605(32?) 1113 110.11 <.083 patients wlltl NM. 83575(65) 15121)51) ‘.088 141)119 —IS?) <081 I 2 1110115 11811 1194(18.91 ‘.081 1611115 —176) <.080 - METHODS 13 2l9l52cI 510115581 <.081 !Iowltal ret me Hospital rflimt 0951080-0901 <.081 Data Source. Study Design, and Sample ‘P°! ilk1 Ill!) <‘ Midweal 1131112—121) <.081

— - 081 - 0.816 Data source: kIid,.esi 126898 dIN 210112?.8l Wed 10110%-IOU West 111120(189l 19% 119.01

Diagnostic Accuracy of The SLU AMSAD Scale for Depression in Non-Demented Elderly

1 1 1, 1, 1 Rita Khoury a Binu Chakkamparambil ‘,John Chibnall iayashree Rajamanickam Aneel Kumar George I Grossberg Department of Psychiatry and Behavioral Neuroscience, Saint Louis University SAINT LOUIS UNIVERSITY Results Receiver Operating Characteristic Curve .i\tialyses and Correlation of’ Introduction — Depression Scales with DSM-5 MDD Diagnosis Dewielivt Anaflaia The sarnipte had a meaa ISO) age Cl 73 5 (7 I) years. 56% In = 26) -were Area Under the Curve Sensitivity Speciftcity/ rho / I women 66% (n 44; were Caitcis an. and 66% (n = 3t had at least, high school aviv sigw&iant getatno depresses, recalls both Despite its nnnpad, (p-value): of education The me SLUMS scoes was 25 9 2 SI. For the depeessia., meass res w.oend.agnssed and underteated (I In the absence of specific dagnostic cntena the - DSM-5 (No vs. MDD) nwiaa scores were e 54.5) ram. 305-15. ‘5.6(11 4) rer tee MAciRs and 49(3 2t for Diagnostic and Statistical Mamial of Mental Disorders. Filth Eaton (DIM’S) cntena the SLU AMSAD The SW AMSAD evidenced adequate internet consistency rehablaly the gold Strela’d d:asostc loot for steele depression Given ffe asTenty represens (Mpha = 77) 30% (n = IS) of palers met 05)4-5 caitena for lCD isafTiosis fact that most etdeely patients receive mental health care in prenary care sessrps (2). Totat Score Nc vs. Any (Mild’ No-Mild vs. Mod- then real raeasr.g need to ness op pratci aagnostt fools to be med by Iflnwv (Continuous) Mod-Sev) Depression 5ev Depression Diaorsoflc Accuracy end correlations care practitioners. in the taihat 603 analysis. tutai Korea (contcoast vanables) for the 005-If. MADHI. AMSAD were evieated in relation to ne D5M-t desi gratian of No .94 1.93? .86/ .70 .79 I 1.0 / .57/ .53 .89 /93 I .86 /75 and 510 The Saint Louis University (SLU) AMSAD tool 5 a bnef (5-item) questionnaire MOD vs MOD AUC vatuen were unilonnty high (5 93), with conesponae5iy high tevets that wan recently developed to eciwen for late-life depression The 5 items reference (< .00t) (< .001) (< .001) of tensi beily .93)2nd spa citcly (a eat Opbmat cutoffs were 9, far GDS- it, ft. fur appetite mood steep, activity snd death ideation using simple tanguage and stating MAciRS ard 7+ mr SIM AMSAD The SLU AMSAD wss equivalent in SOS-ft and Previous research has supported its validity and reliability in cognitivety intad otder .94/93/80/ .70 .69 1.0/37/ .39 .85/.87/.83/ .66 sspenOr to MADRS in these analyses. / estabtiehed categories for the depression meassres were adults in relation to the Geriatric Depression Scate (305)-IS and the r.tontgomety ROC analyses using macsled score results were categonzed as No vs Any (Mild, Moderate or Asbeig Depression Rating Scale (MADRS) 3) The ob1ectve uf th:s study was to (< .001) (.005) (<.001) thea When Sceere) vatses ranged 1mm .69’ 79 with pefleci sensitivity (10) but evatuate the accuracy and retiabitity of the SLU AMSAD regarding diagnosis of major Depression AUC modest epedfioty (range = .37- 57) When score ressiis were calegoszed as No-Mild vs. depressive disorder (MDI)) per DSM-5 asieria in a sample of older adults without .93/85/ .69 .71/1,0/43/ .43 .82/93/71/ .59 .93/ Modetafe-Severe Depression, ADO vaites were again hi5h Is aster 52’ es). with map, neurocognihve disorder (c .00)) (.002) (<.00)) adeqasse ievrts of sensibvity l 87’ 93) ard specifioty 171-66) i. :eover cr55 score cnrreiacacs were newly sadoem scion Vie depewst

-e -. Severe) -3-: etwasuies (6$ 75) screes categorized as No a. Any Matd, Moderate or References Depesssicn yielded ceerelaions we, OSM-5 MDI ate tracge d from 35-53 scores Methodology categorized as No-’ d as .t:orra-esevere Depression 5ielded coerelasens ranging linen 59.75 Whnen scans were categorized accardn to the rcrtrsi oil cli vteSLU 1 Hal CA. Reyrn:de CF Late,lfle depressiras iv toe prensary care setting Chatenges. cocaborawe AMSAC and SOS-IS had rantialon of 75 with DIM’S MOD wS te the MAciRS care and c-rev er2o. M.atun:as 2114 79(2) :47.52 ccrrefac;n was 68 A convenience asinfile of 50 ps:.ercs, a 65 yeats of age was ersoed Uvm4s our speoa)zed genatnc psycmasy outpatient clinic Patents with a clnicat 2 Pdetopoutos Cs New Concepts for Prevenson and Treathnent of Lete-Life Depression Psniencan suspionrediagoosis of mator neurocognisve disorder as refected by a Saint Louis Jounat ot Psychiatry 2001.156(6) 635-8. 1(01 diagnosis was Unieersity Menial Statut (SLUMSI score ot 20 were estluded Conclusions . determined by the treating physician suing the DSM-5 cntena The SLU AMSAD 305’ 3 Chakkamparambit S. Cfebnatt J’Ti Graypel EA, Mar.epslii JN Shudo A Grossberg GT 15 and MADRS. were then independency administered by a member of the research Development cit a bnef vatidated geriatric depression screening toot the SLU - AM SAD’ The The ressits indicated strong diageoshc accuracy far alt three depression states in team who was btind to the MOD diagnosis. Internal consistency reliability of the St-U M’tedcan joumat of genablo psychiatry officiat joumat of the American Association for Genaffic retatios to the DIM’S by hOC and conetational anutyses The Sb AMSAD performed at feast AMSAD was determined using Ctonbachs coefficient alpha Diagnostic accuracy was 2015,23(8) 780.3 aswellas the GDS-15 (three hmet the length of the AMSAD) and siighl’j belier than isa mud snatysis, Psychiatry evaiuated using receiver operating chataderistic curve (ROC) with area under longer and comptes MADRS Hnweeer the dinicat sspensnty of the SLU AMSAP for the curve (*1)3) and sentativilyispecificity parameters cabysted Cogelatons depression screening is tee elderly, in clans to tse other measures. Ic aspponed by the fact the vanous coefficients (Speamtan tho) were calculated between scaeening measures Funding sources mat it encompasses onty 5 simply-welded, simply-scaled items. Thus, she 510 AMSAD and MOD diagnosis emesges us a petersaily seang canthdatr toe drpmssion sctesning in busy dtnicai settings, Nate nckid:r; rnmry care 0;: cr5:, e-eer’seegencyaepunmnl ______What percentage of adolescents at Danis Pediatrics are screened and treated for depression? q Cardinal SAINT LOUIS Olson, MD, M. Susan Heaney, MD, MPH Glennon U N IV ER S I T V. Libby Noonan, MD, Nora ch:!drens Hosp:tal

— ES’ Ill• — Saint Louis University School of Medicine, Department ofPediatrics Background Results Conclusions

• Roughly 1 in S teens experience n(%) Figure 1. Demographics ofstudy subjects • Screening for depression in adolescents at depression during adolescence but only Male 235(42.1) and characteristics ofvisit Danis Pediatrics varies based on the type

about 50% are diagnosed before Age, mean (SD) 14.5(1.9) of clinic visit. adulthood. • Screening is highest at well child checks • The American Academy of Pediatrics (Figure 3). (AAP) and United States Preventative Type of visit • By not screening at all visits there are Acute Service Task Force (USPSTF) recommend 139)24.91 Yes No missed opportunities to diagnose and

screening adolescents for depression with Folowup 80(14.3) PHQ.A performed 391 (701%) 1167 (299) treat adolescents with depression. (91.8%)J a validated screening tool at least once a Well child 339 (60.8) Positive screen l0) 32 (8.2%) I35 • Only 78% of positive screens had some year. Intervention offered 25 (78.1%r’ I 7(21.9%) form of intervention documented.

• At Danis Pediatrics patients are screened Provider level Figure 2. Screening and intervention rate. • Interventions included referral to using the out of 391 screens performed Psychiatry, Psychology, or Behavioral for depression starting at age 12 PGY1 151 (27.1) Patient Health Questionnaire- Adolescent out of 32 positive screens Health, close follow up at Danis Pediatrics, PGY2 111 (19.9) (PHQ-A). and prescribing or continuing mood P61’) 121 (21.7) • A score of 10 or greater on PHQ-A has a related medications. 75% sensitivity and 94% specificity for the Attending 100)11.9) • Barriers to intervention may be due to diagnosis of major depressive disorder NP/PA 75(13.4) lack of familiarity of resources available. and dysthymia.

Provider ‘‘I level of Objectives pO.O4 balnlng Limitations •FSi I •Fc p • Data collection relies on provider • Determine adherence to the USPTF C •Fs, 3 8 I I •A.r4.,o documentation. recommendations for adolescent 37 depression screening. a • Determine the percentage of providers a Future Directions aI p=o.43 that are screening for depression and 0 C • Develop an intervention via the Electronic

offering an intervention for positive C 0 Record that will remind the a Health screens. 0 a provider to administer the PHQ-A screen :1 at all appointments for patients ages 12 to Methods 18. • Educate providers about the mental • Retrospective chart review of patient visits F03W-LC Welch 1 Type of oll9ce veft health resources available for positive Danis Pediatrics ages 12 to 18 seen at July PHQ-A screens. through September 2018. Figure 3. Percentage of PHQ-A performed based on visit type and provider. * Review patient charts from July, August included in study. • Total of 558 patients PHQ-A were more likely to be performed in a well-child visit than in an acute and Sept 2019 and assess effectiveness of or follow-up visit (p <0.001). intervention. ______

Effect of Smoking and Other Factors on Outcome of Mohs Reconstr’ Chang Ye Wang MD, Jacob Duzinski BSc, Derek Nguyen BSc, Eric Ambrecht PhD, Ian Maher MD c.,,4 - SAINT LOUIS Saint Louis University Department of Dermatology, Saint Louis, Missouri ‘LJ. UNIVERSITY (The suthom have no financial disclosures)

Ii I s• i ‘i..

Table 1. Uniyanate analysIs of covadates and outcomes Table 2: Multivariate togist:c regressIon for acute complIcations Smoking is a common lifestyle trait that negatively affects post-surgical wound-healing)2 Age, median (SD) Former smoker 0021. OR 3 15(1 19-8.33) .P,PPLQ 64(1 41-9 ai g r I rate of flap necrosis3 and infection4 No complication 693(122) 696(12.0) current smoker <0.001, OR 912 (3.40-24.4) <0.001, OR 58(3 63-25 3l With complication 683(144) 62.6 (13.8) Defect size (Ln) <0001. OR 210(1 46-3.03) <0001, OR 2.25(1 58-3 20) mean t SD canlIaqe Geaft 0000, 0R7.D4 (1.67-29.6) 0.003, OR 8.19(2.02.33.1) — j TGF-5’6 and collagen synthesis7’8 ? scar Defect sIze, fringe) Other Antiplatelet 0 105. N5 — No cOmp1JcaJDn 3.5 cm7 154) 3.7 czn(5.6) 0 .0001 SI’ 03811 Location 0 296, NS — With complication 6 6 cm2 (6.3) 3.1 cm’(3.2) Male Sex 0 380. N5 — Few studies directly measure the impact of Flap size, mean ± SD (range) complication cm3(14.l) 12.5 cm2(14.6) Table 3: Multivahate logistic regression for long-term complicatIons No 124 0,000291’ 0.0761 smoking on wound-healing after Mohs With complication 20.9 cmt(24.3) 15.6 cm2(16.0) a ‘ann I reconstruction, . ‘ a p-value, odds ratio (range) Female 9/396 (2.3%) 40/396(10.1) Former smoker 0 652, NS — 0,02CC 0,01CC r Suggested to acute complication as a current smoker 0 876, NS — Mate 32)612 (5.2%) 35/612(57) central lace <0 001. OR 247(5 94-103) <0 001, OR 254 (6.16-106) Smoking status (%) Interpolation or covariate in studies pertaining to other topics <0.001, OR 344(1 77-6.68) <0.001, OR 349 (1.81-6.74) Never 6/495(1.2%) 40/495(8.1) combIned (tap-graft <0.OOlc’ 0.334c r The 1 study in dermatology literature only Former 18)385 (4.7%) 231385(6.0) Olderage <0 001. OR 067 (0.55-0.6t)

‘- IBM SPSS v25 Other anti-coagulant (¾) Yes 37/942 (3 9) 71)942 (7.5) References for each covariate o 337t 0.81 tI Univariate analysis - I.. No 4/56(6.1) 4/66(6.1) .-wo.I,sF I&t,,..a.ø Diabetes 1%) eaMve,,r,.a,. —. d,.sj d ‘I* ‘Ifl ll boo 5 — tUeW I, — Iteration 1 of multivahate logistic regression Cdl javIla MsIAboo’, ZlanI d S,Isoo 7.fl4,eili7tE 157 Yes 37)838 (4.4) 61)838(7.3) 2 sane, IT Wa.e eq n lIlac, ,,,,n,y 5o p,ana ,, & .oan o”*. ‘nit’s 0.21St 0.66St laabol a 1* II5MStOOla Seen a .pl.-s ne — ld7 Z2l2.I,e includes covariates with p < 0,20 in univariate No 4/170 (2.4) 14/I 70 (8.2) 3 O’ 0. e 53 C Isa so F.flt-oa 701 A,ae., 0 in 123171 ‘312.1315 Immuno-supprestion 1%) Saicoe, Li Kaboel T r Ac,ooa snec — _.I a analysis Yes 40/969 (4.0) 751959 (7.6) etSe &oOa,flsl (lEi 5 O 5491 0 389t S R*i Mt 5’ LI DIY n5llN 53e.A rrnsI No 1/19(53) 0)19(0.0) —— — — — — Iteration 2 of multivariate logistic regression cv. oeaacv s-aIa,e.,v I.e1 33’ I. denved uang discnminant analysts wtlh ANOVA S Ye Mac k Ts S 7a t, .nx,, q,.a,d th.oe, a 1la 0 rcF.so. using Pearson X2 test Laoo<’iflj dat4saS arx I: s-ai Z515< excludes covariates found to be statistically c: denved I .aee,’o.’ [N, Soda. F O’sa,a., F La. it Ola’ F tl aa. flSo, ifl.,. I- derived using Fisher exact test, for analyses wi expected of observations < 5 a. I23{4)4t,D324 a Sane, LI TOE eQ leWd S — a Lo,a 0 51la19 .eOE’5 ala—’ so Sl non-significant during Iteration 1 -. statistically significant c so afllSa lSa.S dQol edatobe, 50 2Q i4a45tW3’ ____

Neuropsychiatric symptoms in an adolescent: Dig Deeper M. Khan, M.D., A. Tanios, M.D. SSMH&alth Caana,GIennon Saint Louis University, Department of Pediatrics CD Children’s Hospital SSM Health Cardinal Glennon Children’s Hospital, St. Louis, MO

Case presentation Hospital Course Discussion

A seventeen year old female presented with a three month Admitted for inpatient evaluation and management. Major Depressive Disorder is highly prevalent among

- highest being history of Initial workup - blood counts, chemistry, toxicology all adolescents in the United States with the negative. among 16-17 years (17.2%), predominantly females, of • Depressed mood and behavioral changes . fatigue, whom 70% had severe impairment. ‘ Interpersonal Major with severe anorexia, anhedonia and insomnia. She also identified a Pan positive for Depressive Disorder dysfunction with family, partners and peers is a common bladder incontinence, frequent falls. recent breakup as the trigger features. However, trigger for depressive episodes. headache and vomiting could not be explained by an — falls, “Near syncopal” episodes with frequent isolated mood disorder. Cortical and upper motor Psychiatric symptoms often have underlying an medical Intermittent headaches and vomiting, neuron signs warranted neuroimaging for intracranial cause. However, they are a less common presentation of pathology. primary brain tumors.’ Fifteen pound weight loss, There is a delay in diagnosis of pediatric brain tumors Enuresis, that present with less specific symptoms.4

Family history — Mother with multiple sclerosis. Physical exam was notable for (mAcsi tomes,,: 23, • Flat affect, shod attention span, slow thought process. • n,•,,,. — .,.—‘,, ,,.1 !i.

Bilateral pupillary dilation — 7mm, Grade IV Papilledema •rS-j’ it’ Auto Is. • Generalized hyperreflexia, bilateral Babinski’s sign and • ft’ .WTtaff&td ‘r

postural hand tremors • A 4.t1:.-nrs,oat5. .5

• iS,.44.etj Mfl 7% Disease Pertinent positives in our patient • Wee ,u*t • Wroji er Major Depressive Met 7 of 9 DSM V criteria for MDD - •v,-,.,, Disorder depressed mood, anorexia, weight • 5•.,- A — AeAiosh,’6’ loss, insomnia, anhedonia, psychomotor retardation, impaired concentration. Figure 2: Presentation of central/intraventricular tumors1 Multiple sclerosis Age of onset, cognitive Impairment, bladder incontinence, fatigue, upper Figure 1 : MRI brain showing heterogeneous enhancing Conclusions motor neuron signs. Family history of lobular mass likely arising from septum pellucidum Multiple Sclerosis — mother. resulting in obstructive hydrocephalus. • This is a classic case of a neuropsychiatdc interface Normal Pressure Triad of cognitive impairment, where timely diagnosis was very crucial requiring Hydrocephalus urinary incontinence and gaitJbalance • Neurosurgical emergency — Underwent external emergent neurosurgical intervention. dysfunction. ventricular drainage followed by resection of the tumor. Recovered well post operatively, repeat MRI showed A cluster of vague symptoms that do not fit into a complaIn resection of tumor, drains removed without single psychiatric category should prompt a high index Eating disorder Weight loss, vomiting, BMJ - 19, concurrent depression and cognitve signs of hydrocephalus and discharged home. of suspicion for intracranial pathocgy. dysfunction. Histopathology of tumor showed Grade I Sub A thorough history and complete physical examination ependymal Giant Cell Astrocytoma (SEGA). including neurological is important and neuro:maging At follow up, she had returned to baseline behavior and will clinch the diagnosis. a Table 2: Neuro mood with weight gain and complete resolution of Frontai Luue Upper MotCr Neuron unnary symptoms and headaches and normal References Behavioral changes Bilateral dilated pupils, neurological exam ii;I’iI’ M.zr oez,ess:on 5:atisi,cs 2016. Beasiry Pi, Boa So WR. bep,ecc,sn in ise adtiescer.i caijer: • Bladder incontinence hyperreflexia, Babinski’s of ihe Ad R6vi0’,S 262 Since, SEGA is a tumor that is almost exclusively M,.r:ne S,ie lasS. 9(Z 351 • Flat affect, poor attention positive 3 Wdne 5, CcX,eri kennedy C, Knee, K, Gwndy A, Waike, 0 Pr. .1:00 Of in Tuberous Sclerosis, she received a genetics childhood CiIS tumourl. asy,temat,c reef and meta-anai -ei span, slow response identified evaluation but did not meet any other cnteria. Cocci. 2007;a:6a5-95. ______

, Off-label Use of Dupilumab for Pediatric Patients with Atopic Dermatitis: A Multicenter Retrospective Review

Kuda A’. Igelman 5’, Sheikh U’, McWilliams A’. Soothe W2, Fraile C3, Smith A4, Jackson Cullison S5. Shah 5°, Arkin L7 Stegfried E’ SAINT LOUIS u,weILn, usA titess He5CM PNadehia. st Len U’rn,say .i,d ca,aiai Oitnw, Hopl.i. SI Less, MO, USA elkns ,tAssh, Del Metal SaWal, AinIr TX. USA. ‘VMs U ‘sty Sded Di M,sw. N,,-. Have.,, ci. pi UNIV ER St T t Hei Manna,. USA PWa&bhe, PA. USA ‘uientr sI Ptk_b.,, Meai cciv,’ PinsasM, PA. USA ‘U,.vnsfly .tcalloeia aisan Ft•nca Sw. F,nsw. CA.USA. urwe,sty ctWac’ea. Sdssi olMethsse & P,1Ac Wi. IDI.PAKI Ml Nt 01 — clii... — “I KIt cr01065

-a Background/Aim Results Conclusions children Dosing This review supports dupilumab safety and efficacy id 6 I Dái1 Do,. R.a1. earn in children with mod-severe AD - Dupilumab is an anti-IL-4 receplor monoclonal r109• Demographics. mean age at tee) antibody. USFDA approved on 03125/17 for dupifumab initiation was IJyr (3-18; 30 = 3.9); 1’ 53/571930%) t6/54{906%? adults with mod-severe atopic dermatitis (AD), 11125)18o51 • Despite off-label use, access to dupilumab was 41% female S-Il 6117125 3%t r dosed at 600 mg (loading) and 300 mg c,., ifl 1* 3 generally granted, after a delay - Prior Hospitalizations for AD: 36(32%) (maintenance OOwk) • Loading dose used (N=79) • Prior systemic treatments -600mg (adult dose): N59 (75%) • Optimal pediatric dosing is under investigation • Industry-sponsored pediatric clinical trials -anlihislamines: sedating (82%) -mean age 15.3 (range 108—18; SD 2.1) including children 6 mo are in process, but the - anlihistamines: non-sedating (79%) -

children I Gutlman-Yassky . et ai. Two Asthma 71 (%t Efficacy Simpson EL, Sieber T, E. Deck Phase 3 Tnals of Dupitumab versus Placebo in Alopic , • Mean duration of treatment: 9 mo (range 1-19 Unicana 34 t31%) - Dermatitis 2016,375.2335-48 mo) N EngI J Med. 2.cork Mi, Thaci D oiciocdo AT, Davis JO, et ai. Contunuivills • # doses 1-72 (mean 16.5) lvi - Pharmacokinetics, Safely and Efficacy of Oupitunab in a etIi od Eosinophit’c Esophagitis 10(9%) • Modified GA (5-point scale) available for 80 Pediatric Population vnlh Moderate-to-Severe Alopic patients Dermatitis. Results from an Dpen-Label Phase 2a Thai. • IRS-approved, retrospective review -Baseline: moderate 29% (23); severe 71% (57) k American Academy of Dermatotogy 2017 presentation i tttnI:rrj - Follow up improvement: .1 3. Wang F P, Tang XJ. Wei Co. Xu IR, et at Dupitumab :. , treatment in moderate-to-severe atopic dermatitis: A AD0/ADHD 15 t14M • 70% (56) 2-poinl IGA 7 collaborating centers with Pedialric - systemalic review and meta-anatysis Joumat of • • 22.5% (16) 1 point Dermatologists - Dermatoiogrcat Science 2018: 90 190-lOS Other 37t33%) • 7.5% (6) no improvement 4 Goodetham NIJ. Hong HC, Eshtaghi P. Papp (A. el at. iueiv *eenuaI t,e,o...-ca,c.,... -*is.,,r2_—zi—,w •3 of the & non-responders received 2 doses Dupitumab A review of its use in the treatment of atopic alt pediatric patients, an, dermat:’s Records reviewed from - Incidental findings resolution of longstanding J Am Acad Dcrrnatot 2018,78t3) 528-536 age 0 to <18 years. who were prescribed molluscum and warts, improved mental health s. Simpson EL, et at Dirnitumab Efficacy and Safety El Adotescents With Mcderetn.to-Se,sere Atopic Oermahtis. dupilumab forAD I z.. : .i Adverse Events Resuits From a Mtjt:center, RandomIzed. ptacebo-controtted, Fomncte, 24 t22%t Doubte-Ot:nd, Pararet-Group Phase 3 Study. Presented at the ‘ -‘.rr.siia 21 month data collection: 03/25117- 12/21/19 Sinusitis 23 21%) 27th annual EADV conference, Sept 12—t6 2018, paris, 51*Sln, 3-1% 614.5% Locatired Hsv 17 tls%t France tn%,,ee.t •3% 9110fl 6.Siegthed Ec, et at. Use of dupilimab in pediatoc atopic forms and Ecrena 17 Standardized data collection used rirrpettcun tlS%t L51.e, tnen,a, M1• 23% 7 2-u 1% dennat,:’s Access, dosing, and impbcations tot managing entered nb Research Electronic Data Capture rreq.,,nt ot,t;s Media 13(12%) FoMlee,ee 63% severe atopic dermat.hs. VLtey Pethatric Dermatology. 2019. (REDCap) secure central data repository Gro-ipAstiep iajimt w,tjw*pn’i 36: 172-176 No AC liste. rsptsd dupiamab vealneat Pneumonia 7 (6%t There wat nety t d,scsnt,’uati on, due Co lack at eScacy • after 6 moit2 delco ______Actual VBAC success higher then predicted success among obese gravidas It MD; William Perez, MD; Gilad A Gross, MD; Laura K Vricella, MD SAINt LOWS UN VERSI TV Rebecca R Rimsza, M Saint Louis University School of Medicine, Department of Obstetrics, Gynecology, & Women’s Health SSMHeaIUh Abstract Objectives Results Table 3: Potential Contributors to VBAC Success in Class Ill Obesity Background’’ the Maternalfetal Medicine Units IMFMUI Netwoik piedictine model, Primary Obiedive

increasinghodymassindeu(eMIl reducesthe likelihood ofsuccessfuieaginalbirlhafter • We sought to compare the NICHO MFM’U VBAC prediction calculator to VBAC success VRAC RCD -- OR (95% CI) aOR (95% Cl)

— — ?Av %Zitetcm b among patients at Our institution stratified by WHO DM1 Classification N Total = 148 — 91 57 a’ ateitialoliabo in sai an T0l.A() calcomesaccor ding no BM1 group and deteimine ifveAcsurcessm ay be higher Demographics I hanpiedicted stung he MFM-U piedictine model- Secondary Ob)ectives African American 74181) 47(83) .93 (.39, 2 19) .37 (-.16 — 1.4) • To identify factors predictive of VOAC success among patienls with Class III Obesity (DM1 Hypertensive Disorder Study Design ihis was a retroipeclmecohail study of single tonpiegnancies a 37 weeks > 400 Chronic 24(26) 14(25) 1.10 (.51, 2.36) 1.2 (.5-3.3) anara demic tertiary a necenier Eaciasist cniiei,a mete males fetal kg/mi andeigoing TOLAcaI (.25, 1-12) .61 24’ 1.5) anomalies, feiai demise, and greater than one presioascesanean Dafawepecellecied Pregnancy-related 19121) 19(33) .53 ( via individual than review and analyzed by maternal BLIP categoiyai detivery lean fr Results Diabetes Gestational 4(4) 8(14) .28(03,93) 1.7 ( 46-6.14) Pregestaflonal 10(11) 6)11) 505 I 36, 3.06) .33(074.5) usingihepihLshedMPMUca’c’Jiatcrntimarymalcomewasifieditferencebetwe.n Figure 1: Predicted versus Observed TOLACSuccess by SM) Category kg/mI — predated V8A(successvua Ow MFM-ucakuaanoeand wjrohtenedvwacwcces,tate AMi 45.1:42 46.7±5.3 1.12 (1.02-1.2)

secondatyoi,tao,e.eswereadvene watemaland neonatal ias Groups wetr 3331: 3413± .. 1 (.99-1.001) “ so d socceus”tr_’n comcatedus,ng,tudentt-test.clwsquaeed,andANDVA.Petlsssaseoe,sid,red - p’.t — 475 ° I clean Pt. daled Success Rirthweightlg) I 512 Secondary with 855 >50 hg/mi arnofng significant p ‘-.611 sigsf.cant ar.alytisol patent Obstetcic variables variables fur peedct.re Ta noon of VOAC siacess Recurring indication - 25(27) 18(32) .82 (40, 5.69) .76 (.31-1.83)

Renuits: Cl 1397 vtaCanemptsunderlaken between 20112011. 1019 wet study Prior vaginal oetivery 52(57) 16(28) 3.42’ (1.68. 6.96)- 1.15 (.65 — 4 71) critetiaa rid were ae,aiyoed 519 150%) we,e obese, 211 II t%l hypettett;re. and 103 Previous VBAC 35 (39) 5(9) 6.5O (2.37, 4.42 (1.2.15.96) eMi rtatesot prircesarea 0 I ci aftest ,t labor flO’,il diabetic g’oups had sinsb l 17.85) Hype’ tenset, d,a heirs, and tbck racei rota ted w.th OMi p r1 for alil vBAc .3-2 success de creased wits ,ncneasiiig SMI (p = .1) observed and pted.ctrd VUAC nuccess induced Labor 42 (46) 36 (63) .50 (.25, .99) 1.05( 77) wete um,bt sq lean arid sverwe’ghtwsesten (pal), bet ohsetved uKcess was higher Oyutocin use 25(27) 6(105) 3.2 (12—84) 1.12 (1.02’1.22) than piedne die, (less fl, and ill obese women p £ DII Uzetle. tuptuirirat syria Ii Maietna I ad,eisecatzunws ,nckidiz uteitne tuptute, WU ad.’t,sss,ce. arid hysiergc t amy were simitaeamueg SMI troupsasweee rentata I outcome, and MCLI admission. 5 minute APOAR scote less titan 7 and umbaical artery pH less Then 7.1 In>.? for aid Secondary analysis ot Class iii obesity demutytnate d gestational diabetes, ptsmarycesaeea n fot artrst of labor, male,nal tt.Il >50 and induced tabo rnegativety Conclusions to pteviousvaginai dei,ver’es price VeAc associated :11111111 ptedtcted yeA’ succe ssinconttast with hig her success (OR 342(1.61.6 96)) and (6.50 (2.37-tI es) eenpentnely. predicted among obese with incieasitg maternal eMI. women Observed VBAC success rate was higher than conclusion: While VGA (success d encased obese ilLs 390fl> mo ta_n isIs,, 41 had gteatet success than predicted. Theimpact of obesity on VtACsuccessmay be Ii patients. Maternal Detwety BMt Ike/mi iuwer that predicted by she MFMU modeL Observed VBAC success was similar to predicted success for non-obese Background Table 2: Maternal and Neonatal TOtAC Outcomes by DM1 Category — patients. iBMt Category (kg/rn2) <25.0 25.0-29.9 30.O’34.935.O’39.9 40.0+ P Obesity is a significant contributor to both antepartum and intrapartum Total, n 1039 260 265 223 143 148 Maternal and neonatal outcomes were similar among all BMI categories. corn ptications. TOIAC Outcomes Observed VBAC N (%) 207 (80) 203 (77) 170 176) 100(70) 91(62) .001 Among patients with BMI >40, the following (actors contributed to VBAC Key complications include increase primary cesarean deliveiies, wound predicted VOAC Percent 76±13 13±15 66±18 60±19 46±19 <.001 success: TOIAC anempts ending in repeat infections, and hemorrhage and Observed-predicted (A) 4 4 10 10 16 <.001’ o Prior VBAC cesarean delivery results in even higher maternal morbidity Maternal Outcomes • Oxytocin use

Uterine rupture 3)1) 5(2) — 2(2) 1(1) .4 BMI Obese women euperience lower rates of VBAC and is associated with a 1(0.5) 1 (fl.6( 1 — .9 negative predictive value in the Eunice Kennedy Shriver Maternal Fetal CU admission 1(0.5) (0.9) Hysterectomy 2(2) 4(2) 2(1) 1(1) — .6 in Medicine Units (MPFvS’U( VOAC predictive model, The Finding of higher than predicted VBAC success the obese population Tconsfusion 13 (5) 13 (5) 7(3) 6t4) 3)2) -5 should be considered when using models to predict success in this Neonatal Outcomes population. Study Design Birth weight (g) 3180±510 3280:490 3280±470 33SOt44o 3370±490 .001 >3000g 13(5) 19(7) 13(6) 13(9) 16 (11) .2 Retrospective cohort N1CU admission 16(6) 20(8) 23(10) 11)8) 13(12) .2 References Sintieton tern pregnancies between 2011-2018 iwhemic [ncephao,athy - 1(031 2(1) 1(0.7) .2 Hyrrsic Grobman WA, Lai Y, Fandon MB, Spong Cf et al; National institute of Child Etdusi on criteria APGAR score Multiple gestalion, rnaior fetal anomalies. gestasional age Health and Human Development (NICHD) Maternal-Fetal Medicine Units I rninute 8 (7,9) 2(7,9) 8(1,9) 0(7,9) 8(8,9) .4 37 weeks, non-low transverse hysierotomy, 1 previous nonsogram For prediction of Minute 9(9,9) 9(9.9) 9(9.9) 9 (9,9) 9 (9,9) .8 Network (MFMU), “Development of a vaginal cesarean delivery 5 7(3) 8(6) 7(5) .3 birth afeer cesarean delivery,” Obstetrics and Gynecology, volume 109, Comparison groups minute APOAR <7 8(3) 5(2)

—- 806-12, a Lean eMi <25, Overweight: DM1 25 O’29 9, class I Obese: Lunbilical artery pH <7.0 3(1) 4(2) 5(2) 2(1( 4)3) .8 pages 2007. 30.0.33.9, Class II Obese: BMI 35.D’39 9, Class Ill Obese: tatarre.entedanNl%iueueat,n_30 >40 ______

/( a? 5 Prior vaginal delivery in trial of labor after cesarean: Is there a dose response? 7 Rebecca Rimsza, MD; William M Perez, MD; Laura K Vricella, MD, Gilad A Gross, MD tAlNr LOUIS uNtYresit, R Saint Louis University School of Medicine, Department of Obstetrics, Gynecology, & Women1s Health SSMHeath Absfract Objectives Results

Objective: Prior vaginal delivery is associated wit hsuccess tslvaginat birth after Primary Outcome Table 2: Maternal Demographics by vaginal parity cesarean (VOACI. However whether vagina ‘parity has a dichoromous or continuous Successful VBAC according to number of prior vaginal deliveries [Prior Vaginal Delivery None One Two Three Pvalue s lest wetidescribed. We sough’ to evaluate the effect relanionshipwilh VOAC successi Outcomes of the number of previous vaginal deliveries on VEAC nurses srates and whether this Secondary Total, N = 1193 272 135 l 151 finding was applicableno patients with more than one pri orcea inandetivery. variation in successful VBAC by number of prior vaginal deliveries in women Age (years) 27±5 ‘ 29±5 30±5 33±5 .001 - with two or more prior cesarean deliveries patients undergoingToLAcat an Study Deulgn: A retros pecnieecohort strdy of [BMI (kg/rn2) 35 ± 8 34±7 i 35±7 35±8 .3 Composite maternal morbidity academic Ic nary institution between 2011 and 2017 Enclution cli len a included fetal IVBAC Success 417 (66) 212(78) 117(87) 131(87) .001 demise and gestatronal age < ti weeks. Data were collected via individual chart review Composite neonatal morbidity 37(14) - and analyzed hy comparison groups determined hy number of prior vaginal deliveries. 1>1 previous CO 89 (14) 15 (11) 10)) .09 Primary ourcomewas TOLAC success. Secondary outs omen inc laded composiTe maternal Race morbidity lu terine rupture, hysterectomy, and inlenuieccare unit adm issi vol and African American 395 (62) 182 (67) 99(73) 112(74) neonatal composite movb:dity umbilical artery pH tess thati 7.0. N:cu admission, and 5’ Results Caucasian 182 (30) 74 (27) 24 (18) 13 (15) minute AP0AR <‘I. Chisquaredan-d AN0VAwere performed for analyst. A p value .05 was conurdered n gnficant. Figure 1: VBAC success increases with previous vaginal parity Hispanic 22 (3) 4 (1) 3(2) 7(5) 3(1) Es Asian 10 (2) in) in) A rotal of patients net inc!iosio ncri:enia including 1031 with one prior 1 prior CU • 2 prior CD • Cohort 1192 Other 20(3) 9(3) 8(6) 8(5) .01 cesa rean and 151 with two or more prior cesareans. With one previous cesarean, TOIAC peDal pc.2 ps.QQ991 success increased s,gn’ficanllywirh I ncreasing numbers of prior vaginal deliveries for no Tobacco Use 243 (38) 102 (38) 55 (41) 72 (48) .4 priorvaginal delivery, one, two, and three or more prior vaginal deliveries, p <.001 lIable Hypertensive 1). Composite maternal morbidity was similar among groupn. p v.3. Composite neonatal SI 51 SI 57 90 57 vs Chronic 42(7) 29(11) 18(13) 17(11) .02 rnorb.d.tydecieased withi ncreasingvagistal parity, p< .001. Among partents with two

previossce sarean deiiveriea there ivanarre nd toward sgniticanr Inc reanei n TOLAC 7c — Pregnancy Related- 94(15) 29(11) 19(14)28(15) .2 tucceesfrom £4 %w.rh novafin at parity to 68% with one prew out vaginal delivery, 27% Diabetes neonatal w,lh two previous, and 50% w,th three or more, p<.2. tot hmarerna land Gestational 11 (6) 13(5) IS (11) 11(7) .1 mcrb.d.ry we re no’s-signif:cann in patients with two or note prior cesarean deliveries. 70 66

- . 7(3) 4(3) 7(5) Pregestational 19(3) - Conclusion, The positive inflaerceof previous vaginal delivery on VOACwas confirmed. S0 [Labor Characteristics A dosereiponie relationship between number of prior vagLnal deliver iei and succennful ci Induced Labor 253 (40) 98 (361 53 (39) 65 (43) .6 VBAC was observed. For pa tietts with Ste prior cesarean delivery, nan.mum benefit of so Otytocin Use 161 (25) 111 (41) 46 (34) 47 (31) .001 vaginal parity so bserveda her two prior deliveries. A similar, yet nonsignificant relationship is seen in patients with multiple prior cesarean deli v.ties. Initial Dilation >3 238 (37) 153 (56) 81 (60) 96(64) .001 3. 30 Background 20 Conclusion Previous vaginal delivery is associated with higher VBAC success. no Increasing vaginal parity was associated wish higher rates of VOAC success. The Eunice Kennedy Shriver Maternal Fetal Medicine Units (MFMU) VBAC predictive model identified prior vaginal delivery as a predictor Number of prior vaginal deliveries (n) After one prior cesarean delivery there was no significant difference of successful VOAC in a dichotomous fashion between two and three or more prior vaginal deliveries The influence of increasing number of prior vaginal deliveries on VOAC Increasing number of prior vaginal delivery in women with one success is not known Table 1: TOLAC outcomes according to previous vaginal deliveries prior cesarean is associated progressively lower composite neonatal One Previous Cesarean Delivery morbidity. The established protective effect of prior vaginal parity s reassuring p Previous Vaginal Detivery None . One Two Three or more Value two prior alger one cesarean delivery but whether that extends to — . — 141 N 546 234 I 120 In the setting of 2 and 3 prior vaginal deliveries, women with 2 cesarean deliveries is less clear VBAC Success 361 (66) 190(80) 105(87) 122 (87) <.001 prior cesareans experience VOAC success similar to women with 1 Uterine Rupture . 12 (2) 3 (1) 1 (0.8) 1(0.7) .5 prior cesarean. Study Design Composite maternal morbiditr 6(1) 3 (1) 2 (2) 3 (2) .8 Composite neonatal morbdityt 61(11) 11(5) 4 (3) 2(1) <.001 The number of prior cesarean deliveries and she number of vaginal • Retrospective cohort study Two or More Previous Cesarean Deliveries deliveries should be considered integral parts of decision making in • All patients undvrgoinglOL4c between 2011-2018 Previous Vaginal Delivery None ‘ One Two ‘ Three or more ‘i’Value Enclusion criteria

. . N - 89 15 10 j References Fetal demise. gestational age <37 weeks • VUAC Success 57(64) 25(68) 13(87) 9(90) .2 • Coniparison groups: vaginal parity° I. eweicrita tabeianeeceiaieae s,twen,-,cevd,esitvaw.,swvewe otdetuneeeeazntareLs2al2 Uterine Rupture . 2(2) 1(3) - .9 • None en ni 2ta,,dunrt C ten I.trti’j cnaiea. teatime iade,saiiaeteatta ‘assess of War ti raw, aCe, piesiaw Cortiposite maternal morbidity1 2(2) . 2 (5) - - .6 • One prior COO 2ts5 sc;ttna Ps2i.Iliê! Composite neonatal morbidityt 14(16) 7(19) 2(13) 1(10) .9 5 Gntnia.Wa.Laie.LaidaeMu,tfliecv ciii Na,.aesies,isa,e,ita,ideeawaeaeneiae Dea.lnpveei • Two prior INrcv.siMa,ew&.naiaieaaninettensNn’e: tisiiI.Ici. ‘aamreen.e.,i ci a,,sevemii, teir,ediui.eeei t,.thafteiueweandii, me’ Otstei ,aeatnva,einn. esl.na KS. ranesmesI. OW, a Three or more pdor vaginal deliveries .i..n.’oaiive, aeviemvts,e,tei. nilvtaeieu.it naenai v - Nimedesivee. mSeesveset vc:s •vaeinalpatrte-derined asnsmb.telnr:-. seal - wets nswswvai awn pa 7e, ______Three-Dimensional Printing in Pediatric Medicine and Surgery e) Caitlin A. Françoisse, MD1; Anne Sescleifer, BS1; Alexander Lin, MD, FACS1’2 1Divlsion of Plastic Surgery, Department of Surgery, Saint Louis University School of Medicine SSMHeoIch tØi SAINT LOUIS UNIVERSITY 2St. Louis Cleft-Craniofacial Center in SSM Health Cardinal Glennon Childrens Hospital at SLU Card nalGiennon Children’s Hospital

INTRODUCTION PATIENT-SPECIFIC CLINICAL UTILIZATION OF 3D PRINTING

-- ri 3DP Manufacturing Three-Dimensional Printing (30P) DESCRIPTIVE STATISTICS r.nr kill!:]: • Manufacture ofan object by adding thin layers of material in succession to create desired shape Number of Patients (n) • Allows for rapid, low cost production of high fidelity Total for all studies 508 WoeMeepnrtatce models Patients and Families SOP model of congenital heart defects to explain a child’s Why 3DP in Pediatrics? Average per study 3.6 anatomy to palienis and famiRes — • Pediatric patients have compact anatomy that 1 - 50 — I Range of studies Medical Staff require higher degree of surgical precision Age of Patients 3DP models of congenital heart defects used in KU seeing to • Can have unique congenital anomalies not always educate nurses about their patients’ unique analomies I captured on limited views provided by imaging Average of all studies 7.6 years Patients less tolerant of anesthesia or blood loss • Range 7 days —18 years • Allows parents to understand a child’s illness without the ability to read medical imaging Imaging (%) Selection Computer Tomography 64% 3DP models of congenital heart defects help detennine if a 1. DescrIbe most common manufacturing variables patient needs surgery and if so, what type PURPOSE 2. Classify 3DP items into categories of use Three.Dimensional 9.4% Simulation simulate stenting 3. Describe which specialties are using 3DP and how Pholographic Scanner 3DP model to endovascular Magnetic Resonance Imaging 8.5% 3D? model used to simulate correction of hip dysplasia ATTRITION FLOWCHART Modeling Software (%) Materialise, Leuven, Belgium 36% 3D Systems, Rock Hill, SC 4.8% Positive Contour model used as reference in OR during congenital heart surgery __ 3DP Cybermed Co, Seoul, Korea 3.4% Guides N Printer (%) 3D? models bull specifically to assist with placement of screws in orthopedic surgeries Stratays 15% tia aj..p ia l -. r Splints 3D Systems 9.4% SOP mcdels used so hold dental occlution in final positioning during / Z-Corp 5.5% orthognalhic sulgery IJ L4J LJ Implants Makerbot 3.6% 3DP models as Gaston, cranial implants In cranioplasty Production lime (hours) STUDY CRITERIA Average 14.4 Range 0.42—108 Shaping Custom 3D? nasoalveolar molding templates to mold cleft nostril (USD) INCLUSION CRITERIA EXCLUSION CRITERIA Cost based on non’cleft side Average $895.80 Substitution 30? hand and/or upper extremity prosthetics for children Range $20.75 -$4043 The clinical focun of thin review was I Reviewt, technique articles, editorial,, book chaptem, methods papers, and Incomplete the use of 3DP in patient-specitc Cardlothoracic Gastrointestinal & Abdomen articles (eg, only abstracts available) Craniomasillohcial pediat,ic care. Adrenaleclomy 3DP Use by Specialty ‘ Congenital Heam Disease 2 Wtden not available in Engliuh . Airway intubanion Ccartlatioo of Asna • Liver Transplant use of a patient Studies that included patients ages 19 and . Cranioplasty/Cranial vault Remodeling I Involve the Double Outlet Rght Ventrt:le Hepatectomy speciFic 30P object, report oer . Detsistry/omlaciet Surgery - Heart Transplant Tumor Resection pr:mary data, and be L-srd in the 4 Articles damlbng SOP objects that were riot . Ostracton osteogenesis ‘ Pulmonary Atresia Genitourinary System diesical care of a patient patient-specific leg, teed in care of muftipie em . Masillomandibular fusion ‘ Transposition of the Great Artenes ‘ cloacal Malformation 2 Man-ahctum a SOP object by patientsl. or articles in which the SOP object ‘ Microtia Rrparr/Auricular Pmsthesis Trunsus Arteriosus . Odro, Resection joining material layer by layer, wan not directly involved in patient care . Nasal Atveolar Molding/Orthodontics C--— • Tumor Resection Lower Eatremity known at the addItIve method 5 SOP obiects produced by method, other than ‘ Orbital texr-ctsu-tion • efl • vascular ‘ iooe:tivr Osteotomies 3 Address the pedatric pop-a!alioO additive nmrvalactuhng, including subtractive . Recontti -: ‘ on following trauma • Ventricular Septal Defect ‘ clbtsot def.ned as patients up to and n,anulectwieng. 040 mdSrng. and prototype . Reconc’ ontollowing tumor cenlral Nervous System ‘ Developmental Hip Dysplatia including the age of IA yean old machining • scalp It:, . rage Cervical spinal Fusion ‘ - rb lengthening 4 Both cane studies and case series 6 Cadaver studies ‘ skull o - : ct - kt,nin gomyelocele ‘—red Capita I Femoral were included. Animal studies ‘ Tempc - bular loins implant - 2oliosis . Tracis ‘ Tumor Resection Resection Hearing Hypernasality: Online Crowdsourcing of Cleft Speech Anne Sescleifer, BS1; Janna Webber, SLP-CCC2 Caitlin Francoisse, MD1; Joy Baltz, BSN2; Jeffrey Rector, MA3; Alexander Lin, MD, FACS1’2 SSMHeaIch SAl NT LOUIS UNIVERSIT Y Department Surgery. Saint Louis University School of Medicine CordlnolGlennon 1Division of Plastic Surgery, of Ch,4req’s Ho,p,iai 2St. Louis Cleft-Craniofacial Center in SSM Health Cardinal Olennon Children’s Hospital at SLU 3Department of Psycholoqy. University of California Davis

INTRODUCTION RESULTS

ijI Pm : • Cleft palate is a structural defect that results in an opening MTurk Speech Ratings a.TL...... l!, i between the roof of the mouth and nose (Fig. 1). This prevents wo.Pp>zc,n)ss)Kc Phrase Accuracy: 4 yrs, the palate and pharyngeal muscles from restricting air flow to 1.0- P1 2 years 2-3 2.62 the nasal cavity during speech (velopharyngeal insufficiency), ‘C -- p:c.2t •.. PioxI understand and socially stigmatizing.’ C which is difficult to m m P2 6.5 years 2 1.76 pathologists (SLPs) conduct clinical speech • Speech-language 0 0.5- assessments, provide speech benchmarks throughout 5s OeN Pain ‘C p Pre’np 3 2.65 treatment, and work with children post-operatively to correct 0 NI p compensatory misarticulations.’-3 ‘mm 0 0.0- [‘] Table 2. Demographics. SLP score, and MTurk mean • The demand for SLPs exceeds the supply: disadvantaging E for each of the patients recruited in this study. For populations limited socioeconomically or geographically. each patient. MTurk mean was consistent with SLP IB score when rounded to the nearest whole number. • Online crowdsovrcing of perceptual speech outcomes may S -0.5- U Figure 2. The phrase accuracy of each phrase was present a solution to the immediate need for speech Figure 1. cleft paiate is a structural C and widely calculated as a residual (its distance from the gold evaluations that are rapid, consistent, low-cost, defect resulting in an opening -a accessible to cleft patients.5 between the roof or the mouth and IS) standard): which leads to WD being more accurate -1.0- I (smaller distance from gold standard) than PP. which is • HYPOTHESIS: Online crowdsourced lay ratings of cleft speech the nasal cavity, allowing air escape 0 I during speech. more accurate than ZC. than U. than 55, than KC. with SLP ratings. WD PP ZC rr ss KC for hypernasality will be highly concordant The column bar graphs below represent mean. SD, Speech Phrase and statistical significance levels from Tukey post-hoc METHODS pairwise comparisons. Recruitment. In our RB-approved : Patient Code Phrase tJ*t study: patients with history of cleft palate repair were recruited. IC Katie likes cookies. P1 2-3 2.25(0.92) 2.97 (0.99) 2.93 (0.94) 2.19 (1.03) 2.75 (1.23) Voice Recordings. Speech phrases U Tell Ted to try. collected at previous clinic visits were WD Should I wash the dishes? P2 2 1.56 (1.28) —- 1.49(1.09) 1.38 (1.18) 1.40(1.10) 2.97 (1.08) recorded using videonasendoscopy (VNE). Specific phrases selected for hypernasal PP Peter has a puppy. P3 3 2.15 (0.90) 3.32 (0.88) 3.24 (0.95) 3.49 (0.80) 1.96(1.16) 1.79 (1.21) speech were extracted from VNEs using 55 Sissy, sissy, sissy. Table mean MTurk rating of each specific cleft-challenging phrase, along with standard deviation, is QuickTime Player (Table 1). Speech 3. The displayed. Phrases represented varying levels of accuracy. when compared with SLP scores. expert ratings based on the Pittsburgh ZC Zippers are easy to close. Weighted Speech Score (PWSS) were Table I. Specific cleft-challenging phrases were CONCLUSION collected from medical records. identified in the videonasendoscopy recordings. for hypernasality are highly consistent with Crowdsourced Ratings. Speech and provided to internet raters ror evaluation. • Online crowdsourced ratings of cleft speech predicted ratings in all three patients. samples were provided to internet raters speech-language pathologist (SLP) ratings, and SLP using the online crowdsourcing platform Data Analysis. Both sentence- • Individual phrases had different layperson accuracies WD—PP—ZC>fl>SS—KC specific and overall mean and Amazon Mechanical Turk. Sound clips • This novel technology had immediate translation in clinical speech assessments especially Likert standard deviation of crowd ratings were rated on a scale: d. for centers without SLPs or requiring further clinical corroboration with expert corresponding to the hypernasal were compared SLP rating. Tukey post-hoc analysis was I. Cinfl.,ifr,.*N l.’.l[,.4.4:ma.paI,.,Aid.—e ph.,..,. ,peAh ddth... —‘:13 — i:Tha,,t deft a.,e CA. fldr pfl,.-3,CA,A,5,dt101tA41 component of the PWSS (scale 04) The el.ipetI

Background Images Discussion

Persistent len si4,erinr vend cava (PLSVC) is a congetral defect a’ 0 3- Dtntg embxyogenesis the sires veaosus is the reservoir (or the 05% at he general population •i 0 anlenorlpos:erior cardinal, vitelirie aid umbiscal veins with dran the • PLSVC is a thoraoc vein anomaly which can drain into the left atrium venous blood, connect to yolk sac and carry mqganaled blood from the ilIlI:ilttiiP_r (shunt) or coronary sinus placenta, respectively • Most often an incldental finding through ecliocardiography or interventional • PLSVC tormation occurs prior to the eighth week at embryogenesis procedures including pacemaker insertion and central tine placement whereby the distal eli posterior cardinal vein fails to degenerate into the • Often patients are asymptomalic if there are no further congenital cardiac Ligament of Marshall 2 or thoradc defects • The left anterior cardinal vein becomes the internal jugular, white the tight • Common findings include dilated coronary sinus and arjhylhmias due to common cardinal vein and anterior cardinal vein form the SVC eclopic pacemaker cells located within the anomaly • There are three types of PLSVC depending on he proximity of hypotension and • Intervention via the PLSVC can preclude to cardiogenic degeneration of the dislal len posterior cardinal vein including direct further ardiylhmagenic rindings in &arnage info rite right atrium lfrwgh the CS orteft attiat s&itV formation • Theretore the understanding of such pataenls must be awae to through an tairoofed Cs interventional apeoaksls to Umit adverse effects • Becomes diedly dii,cay significant with the nghl.to-lefl aiM stka’t and FifuretC’rnynge.eas r,c.tg eti was emme flqer. 2 tflk PaWe1 5th Scan Vasa tea iFtSVcl Ies w4 wtfl patient undergoing interventions involving the tell subdavian vein it tie rzes St esi Pssvc tat PsSvc &a-rg rb awnjwi enfly Case a-a tat 4 ens s’on rwiw &weto-. txees where a central line ox pacemaker lead may be placed in the vnong d — — ca*4 eel en tie U.re4 it as wa Svc meara eat FS[Vc wm S’,t se2{:t ktysral location’ • 56 year-old-female presented with an abscess on the right hand folow.ng Related pathology adudes wsti$hmias. syilcape, cyanosis and other accidental bum-trauma cardiac congenital deformities including septat detects, coardation of the • Underwent indsion and drainage (l&0) and transitianed to oral Cephalexin soda and bicuspid aartic valve on first discharge Most often found as an asymptomafic incldentat finding on • Re-admitted with clinical non-progression and underwent tED and started echocardiography, angiography during intervention or non-invasive on IV ctindamydn. stabilized and discharged on P0 antibiotics imaging (CT, MRI) resulted in admission for worsening wound • Follow-up with Plastic Surgery Treatment in symptomatic patients with cardiac shunt through grafting and closure closure of defect • During this third admission patient noted to have elevated Creatinine and tower extremity edema for wtith tmnsthoraoc edsocardiogram (U El was obtained Conclusions - UE stowed dialed coronary snm aid negatwe bubble study cunsistenl PLSVC Wi ai asymp(omahc patient diNing Sfl with PI,SVC. loflowed by coniirrnatocy CT angiography of the fr,&ng TNs case presents a • Patient underwent amputation of affected 5mb with pathology showing ethocardiography study osteomyettis of the first proximal phataige • PtSVC can lead to nght-tn-left cardiac shunt, anhuyihmias, syncepe and • P1CC (tie placed through right Macui vein may co-exist with olher cardiac deformities • Discharged on 5 weeks of IV Cenhaxone • ‘INs asornaty is pertinent when pectomning interventions buding central Fg’.ii. 5 ha-dna nogeii liuEi heec—stea vee it wq an il-Al liwts (LV). asia lt addlied asatay lute and pacemaker placement me (Cs) serGe A) a-it ate as q& say usc stxtr Lieqi• 5? —. •nn.dwniec- ,-c.a, sa.asie. t’—n’ie,ia, .5 f Ia)

s—S. 5’s,n a. .—e,—.c’—,s V_S. aiie Ii? — e4tas.s..S.s!fliew.ai:a San sas.G - ______—-______—______--______7:3

SAINT LOUIS Appropriate Use Of Telemetry: Indication Versus Gratification UNIVERSITt Julien Feghaty, MD1; Zachary Oman, 001; Adana Mooradian, MD1 ‘2’ ‘Department of Internal Medicine, Saint Louis University School of Medicine

Introduction Tables Discussion

determining Summary of the American Heart Association practice standards for electrocardiographic • ThIs case highlights the difficulty in • Physicians are often in a dilemma in determining the appropriate telemetry use in certain cases. cardiac monitoring in hospital settings’. appropriateness of starling continuous • While our patient appeared to be hemodynamically telemetry monitoring on a variety of patients presenting stable, continuous telemetry monitoring may have been to the hospital. Table 1. class i Indications for Cardiac Arrhythmia Time Frame of Monitoring Monitoring able to prevent this poor outcome. • Most physicians would agree that telemetry monitoring 1. Patients resuscitated from cardiac arrest —- Until lCD implanted • While the American Heart Association (AHA) has arrhythmias, is warranted for patients with syncope, 2. Patients in the early phate of acute coronary syndrome Minimum 24 h, until 24 h after complications outlined a guidance for the appropriate use of cardiac cardiac surgery. lesolved myocardial infarction, or following monitoring, its final use is determined by the other situations are tess clear such as 3. Patients with newly diagnosed high-risk coronary Until PCI • However, physician’s clinical tudgement. patients with abdominal pain, stable pulmonary lesions 4. Adults who have undergone cardiac surgery Minimum 48-72 hour or discharge • Based on the AHA, patients are classified into class I controlled atrial embolism, atypical chest pain, or rate 5. Patients who have undergone nonurgent PCI with Minimum 24 h (monitoring indicated), class II (monitoring may be of fibrillation. cptpplications - — benet), and class Ill (monitoring not ind’cated)t, Patients who have undergone implantation of an lCD 12-24 h 6. our paPent’s extensive medial and cardiac Case lead or a pacemaker lead and ale considered pacemaker • Desplle dependent history, he did not have class 10111 indicaPons such as 7. Patients with a temporary pacemaker or Until pacing no longer necessary or replaced typIcal chesl pain, newly diagnosed coronary lesion, • A 79-year-old male with past medical history ol end nscutaneousjads — with a permanent device or ablation. hemodialysis, undergoing coronary angiography stage renal disease (ESRD) on heart —— pacemaker a. Patients with AVbIOck Until permanent pacemaker or defibrillator placement, acute heart failure with reduced election fraction status-post 19. Patients with arrhythmias complicating WPW Until RFA failure, or syncope. implantable cardiac defibrillator (lCD), coronary artery - syndrome with rapid anterograde conduction over an disease with one drug eluting stent in his right coronary ccessory pathway______-— 10. Patients with long UTsyndrome and associated Until proarrhythmic drug is discontinued artery, chronic atrial fIbrillation, and colon cancer status Conclusion ventricular arrhythmias post left hemicotectomy presented with a 3-day history [ii. Patients receiving 1ARP Until weaned from IABP nausea, epigastric and umbilical abdominal pain, with 2. Patients with acute heart failure or pulmonary edema 24 h after symptoms ,esolved • Physicians need to use clinical judgement when reported black stool following dialysis. [13. Patients with indicationsfor_intensivecare Until hemodynamicalfy and respiratoryscabie assessing for appropriate use of cardiac monitoring or therapeutic Until awake and hemodynamically stable admission found to have cclix artery 14. Patients undergoing diagnotlic while at the same lime preventing over use. • On he was procedures requiring conscious sedation or anesthesia stenosis with an elevated lactic acd of 16.6 mmol& but • Cardiac monitoring may aid is eady detection of cardiac was deemed too high risk for surgical intervention Table 2. Class II Indications for Cardiac Arrhythmia Time Frame of Monitoring arrest, however! current medical research has yet to given his complex comorbidities. Monitoring reveal any change in outcomes for such cases.

- Ml - - — 2443h 1. Patients with post-acute - • He was not started on telemetry as there was no 2. Patients with chest pain syndromes 12-24 h or until negative biomarkers

concern for acute heart failure, despite his history of 3. Patients withçplicated nonurgent PCI 12’24h - chronic hypotension (average; 90/50 mmHg) 4. Patients who are administered an antiarrhythmic drug With antiarrhythmlc drugs and high risk of REFERENCES secondary to ESRO and chronic heart failure with or who require adjustment of drugs for rate control with pro-arrhythmia: consider class I indication chronic atrial tachyarrhythmta reduced ejection fraction (25-30%) & severely I Falun, N - Noedrehaug, .1 E Hoff, RI - Latgorgen. J Moons, P atd 5. Patients who have undergone implantation of a 12.24 h Norekvai, TM, 2013. Evaluatss ol the appmpriatetess atd oslcome tt

function. - -— decreased left ventricular systolic dependent - [pacemaker lead and are not pacemaker in-ttspilai lalemety monioring. TheMiertas ioumal ofcardiobgy, 12-24 h with • On day 3 of the admission, he was found unresponsive 6. Patients who have undergone uncomplicated ablation Normally not necessary. 112(8),pp 1219-1223 and pulseless in bed. Cardiopulmonary resuscitation incessant rapid tachycardia or AV junction 2. Botossias. H, & M, P 0. 12017) Teletnety Monitiag indcats and with successful return of spontaneous ablation with pacemaker implantation Sfralegs to Reduce Orenise. Hospfa! Medicine C!in, 641). 299-306. was performed observation 7. Patients who have undergone ioutine coronary Normally not necessary, only for 3 Drew! 8. 3, CalLS. H. U Fusk, M Kaufman, E. S Kaicoff, M- W - LaSz after 12-minutes. circulation -- - standards to. iapgiogphy -— jpyçtomattc brvçarda M N & Vat Hare. & F (2004) Prac&e • Further lCD interrogation revealed that he was in 8. Patients with subacute hearl failure in subacute phase, when therapy is adjusted electocardimcti moniiitg it tDsulal seussgs: at Aisercat Heail soetsfc catenett from Use Cococits on Cardc.ascjia ventricular hbriiation at 170 bpm pre-arrest, however. 9. Patients whoare_beingevaluated (or sycpe - 244811 with unknownwigin Assa:aoos Dgaasa in the Young 10. Patients with do-not-resuscitate orders with until optimum rate control is achieved Nurs.rg. O& Csd&gy. arid C o.asccl the defibrillator threshold was set at 180 bpm. ecdcssed ty Use hlemaXt Soncty ct Coenpulamed Elecsocarddogy arrhythmias that cause discomfort • Unfortunately, he remained in critical condition and and ibtAstsectatAssocaflcnotCntctCareNurses Ciftulattn, 116417), expired one day later. Av block: atnoventricular block; 1ASP- intra-aortic balloon counter putsalion; lCD impianlabte 277: 2746 card:ovetler defibrillator: Mi: myocardial infarction; PCI- percutaneous coronary intervention; RFA. radiotrequency ablation, WPW Wott-Parkinson-’FThte syndion,e. FH) Diagnostic Approach To Acute Rheumatic Fever UNIVERSITY- Presenting As Polyarthritis Julien Feghaly, MD1; Ariana Mooradian, MDt tDepartment of Internal Medicine. Saint Louis University School of Medicine

Introduction Discussion Discussion (continued)

• Acute rheumatic lever (ARF) is a delayed inflammatory response • The diagnosis of acute rheumatic fever is guided by the modified Table 2. serologic evidence diagnostic value in testing for ARE4 secondary to group Astreptococcal pharyngitis, with an average Jones crileria2. which aims to direct clinicians in the diagnosis of .‘!aIs1lo9Ira-N4IlNi’j over diagnosis. onset of 2-3 weeks following infection acute rheumatic fever and to help minimize Lanti-streptoipln 0 (MO) titer - 72.7% 93.2% • ARF is estimated to affect 33 million people worldwide, with • The criteria require the presence of a preceding GAS infection, in anti-DNase B titer 70.5% 93.2% approximately 47000 new cases & 275000 deaths annuallyl. addition to the presence of two major criteria or one major with two Combined MO & anti-DNase B titer 955% 88.6% • The malority ot the cases of acute rheumatic (ever occur in children minor cut eria (Table 1). ages 5 to 15 years old and in low to middle income countries • Further, supported by evidence of a GAS infection by throat culture, • Once the diagnosis has been confirmed, further diagnostic testing • The delayed response may manifest in several ways which include rapid slrepfococcal antigen test, or elevated or rising streptococcal is required to rule out some of the fife-threatening conditions rebled arthritis, carditis, chorea, subcutaneous nodules or eryihema antibody titers. foARF namely cardifis effecting the endocardium, myocardium or marginatum. pericardium. • These various presentations may often make the initial diagnosis of • This promptly performed by clinical examination, auscultaling for Table 1- Modified Jones Criteria are tested new murmurs and echocardiography, assessing for mitral oraortic ARF elsallenging as several other differential diagnoses in addition to the presence Presence cf a precedig GAS infection, regurgitation3. before amving at the final diagnosis. of two major criteria or oae major wdh two nnor crileha • Murmurs that could be auscutlated are in the selling of valvubtis Major criteria Minor criteria new ap3cal systolic murmur of mitraf regurgitation & Case would include a • Polyarthritis • rever a diastolic mumnur of aodic regurgitation. • Carditis • Arthralgias - Additionally, distant heart sounds can be auscultafed with • Subcutaneous nodules • Elevated acute phase reactants • A 52-year-old male with a previous medical history significant for pericardilis. • Erythema marginatum fCRP, 611) abuse, presented with nine-day • Echocardiogram findings could include congestive heart failure with gout, hypertension, and alcohol • Chorea • Prolonged PR interval history of worsening arthralgia of his right wrist, right elbow and tell ventricular volume overload in setting of MRJAR secondary to in the setting of pencardilis2. bilateral toes, ankles & knees. Supporting evidence of Group A Streptotoccal infection myocardifis or a pericardial effusion • He was treated with indomethacin & colchicine for a possible gout • Positive throat culture Ilare, with no improvement. • Positive Rapid Streptococcal antigen test Conclusions • Additionally, receiving antibiotics for concern of septic arthritis, • Elevated or rising Streptococcal antibody titer having had a temperature of 101.9°F. - Acufe rheumatic lever may have varying presentation and needs to • X-ray imaging of all the involved loints revealed soft tissue swelling - In the process of testing for GAS, throat culture is the standard for be considered when assessing polyarthritis. and no degenerative or erosive changes. the diagnosis of GAS phaiyngif is; however, only a quarter otARF • Various diagnostic testing can be used for diagnosis ofgroupA • Jornt aspiration of the left knee revealed no crystals and was patients will have a positive throat culture. streptococcal infection. negative tor bacterial growth. - This could possibly be due to previous antibiotics use or latency • The combined measurement of ASO and ant i-DNase B liters • Additionally, blood tests revealed an elevated ESR at 9B mr&hr & between initial infection and ARF onset . demonstrates the highest sensitivity. elevated CRP al 17.7 mgfdL • A second, more practical test in the diagnosis of GAS is rapid - Cardiac examination followed by echocardiography is highly • Unc acid levels, anti-CCP, Rheumatoid factor HLA 8-27 ANA. anti streptococcal antigen testing whch allows for diagnosis of GAS recommended to assess for cardif is once acute rheumatic lever 85-A. anti 55-B. Hepatitis B & C and HIV were all unremarkable. with:n minutes in the clinic. diag nosed. • Further testing revealed an elevated anfi-strepfo!ysin 0 (ASO) liter - Yet despite fhe:r advantages, throat culture & rapid antigen testing of 880.3 UImL and an anti-DNase B titerwithin normal limits. may be inconclusive as they do not dillerenliate between chronic • A diagnosis of acute rheumatic fever was made, as the patient had REF ERrncEs pharyngeal colonization and ARF fulfilled the Jones criteria W,lh one major feature (Polyarthritis) and I fideL) tnt” A End ME Ftap.Harai.C T ralwe,si 6 kCrdnt.ogeoJU Ste. - Thus serologic evidence of elevated or rising ASO and ant i-DNase B Ii AP S,’,,esie,sPRaidiV&t’O 2047 two minor features (documented lever and elevated ESR & CRP). R, Sa,,iaA Awt.njie titers is needed to detect a preceding GAS infection & the onset of resin iee au fl.e’,aic eal ±,e eacncIcs5 — thtj xts3eSn,s c,reiti eetrl • The patient was started on a ten-day course of oral peniciln V cnhIso,vfl.1ee.!i.21pIt ARF ITable 2). 1 OnAs Apa C S,AWInFZ Bae.A Oery Fw nan oi Fwei p red u • Transthoract echocard ography revealed no abnonna!ties or any tt leAf • If is still important to reco ne however that a low titer of either U ta FL aid tdra A C 392 GsdA’e h thawns ot eer’ signs of carditis. a,a’.a 992 wdt. JAM& 24I5) pp 4O72 ani ,lies doesn’t exclude the diagnosis of ARE and that high clinical 3 &‘i&Rj .idOwç c 2011 D.,,,ecalnrlaai,t.t,inbee &tAnntyIWe* :L • The patient’s symptoms gradually improved, at which point he was i rp!M3.4O? sos cion should prompt repeat testing to observe for rising titers2. A We On1 discharged a rehab,ilation facility. A E’th CC aid Ptheua, PC 2. Mt-stert4 ai51 ci aifa rd to al99cAdaaw ,3,pvdna,ww3s2e71fl.10 aid deI1rhnleAO PaiwA,q1. 3812i.C153 its c)

I ZIN Q Iflhllilil An increased number of patients are being admitted to the There were a total of 23 patient biopsies performed during the Placing a rush on biopsy specimens when hospital for dermatologic conditions. Studies have shown that study period, of which 7 were in the ICU or in the hematology necessary, decreased the read out time by dermatologic conditions are frequently misdiagnosed by non- ward. The average time to receive a biopsy readout was 3 days, nearly 50%. The read out time for biopsies of dermatologists. Dermatology consultations often result in but if specimens were rushed, the average read out time was patients in the ICU or on the hematology service changes in both the diagnosis and management of hospitalized reduced to 1.7 days. If a dermatopathology consult was took longer than the general floor patients, patients, and thus play a critical role for the inpatient. The most requested, it took an average of 7 days to receive the specimen which could have been related to the underlying common conditions seen by dermatology consult services are in the dermatopathology lab. There was a 50% discordance rate disease complexity. Despite a low number of cutaneous infections, dermatitis, and drug eruptions. The between general pathology and dermatopathology. cases and a short study duration, there was majority of consult requests come from the internal medicine evidence that the timeliness of inpatient biopsy service. read outs needed to improve for enhanced In the inpatient setting, obtaining pathology results in a timely patient care. manner is imperative for patient care. Biopsies aid in the medical decision making process, and any delay in the diagnosis, and subsequent treatment, can delay care and prolong the Avg Time for Bx Read Out (Days)- 1.7 hospital stay.’4 Rushed References IHut, H,ynes H, Fernzza 0, eta). impaci aI speriati connuitaim,s on iep.t,enl Methods ICU/Hem Patient Non-rushed Avg Read 4 admissions to, dermatoisgy-upecilic and reiat.d DRO, I Gen Intern Time (Days) 201 3;23(1 I) 1477-1432. A retrospective study was designed to identify how many Out 2 st,azzuia 1, Coit’ar 1, Fox LP, ego’ inpatient dermatology consult. ion aids xtiagnouix ot takes to receive a biopsy readout by the cetlulitis among hospitalize d patients, a muixi-inntitutionai ana sis I Am Acud Onmotot days, on average, it 20 15 73111: 70-75 general pathology service for inpatient dermatology biopsies. ICU/Hem Patient Rushed Avg Read Out 2.5 3.Kronhinnky 0. coolar 3. Hughey Lç at ci. Asnoci,tion of dermatsiogy consultation with identify how many days it took to receive accuracy ci cutaneous disorde, diagnoses in ho,pit,ii,ed patienis: a cnutticerier,n, iysis. We also wanted to lime (Days) IRMA Oermotoi. 201t;1s2(4):4774g0. pathology slides to the dermatopathology lab if an official 4,Ank,ki RY, Stmzouia 1. Woo E, Kroshinsky D. The impact of dermaiciogyconsu it,tion at dermatopahtology consult was requested by the inpatient on di,gnostic accuracy and ant, biotic use among patients wit h,utpecte d cetlutitis seen Avg Days to Receive Consult Slides from 7 outpatient internal medicine oflicen: a randomize dclinica t trial. JiMA D,rmocot and to identify the discordance rate in the 2014.150(10): 1056-106). dermatology team, Pathology general report and the storan ER, McExoy MT. Wetter 06, en p1. Experience cia year of auit hasp,tai diagnosis between the pathology dermatology connulta tionx. tnt) Vennoroi.2015: 54: 1350—1156 dermatopathology report. All of the inpatient dermatology Discordance Rate Between Pathology 50% & Gatimbefli F. Guren 1. Fernandez AP, sood A Dermatology contuitat,onsnignif,cantly was collected for evaluation from July to csntnbu te oLaity to cane ci hon p’:ai’.oed pat rots: a protpectoe stL ci dermatology consult biopsy data and Dermatopathology inpatient cnss ho at. Ce mary rare center lot) Vermo:ci 20t6 Oct,55)lO).e547-51. December 2017 at Saint Louis University Hospital. Background Discussion Painful mucocutaneous ulcers are one of the most manifestations infection. distinctive of acute HIV Acute retroviral syndrome (ARS) typically presents These ulcers may develop in the mouth, esophagus, 24 weeks after acquiring HIV and presents with or on the genitalia. of the incidence anus, Estimates fever, LAD. myalgias. sore throat, diarrhea, rash of oral ulcerations in acute HIV range from about 9- (most often maculopapular). weight loss, and The for individuals 30% of cases.1 differential headache.2 Although not seen in the majority of presenting with new onset mucosal ulceration, cases, painful mucocutaneous ulcers are a edema, systemic truncal facial/lip symptoms, and distinctive and helpful feature in diagnosis.1 This morbilliform exanthem is broad and can include case was challenging due to the profound reactive drug eruptions autoimmune severe such as SJS, soft tissue edema that accompanied these and infectious etiologies, making blistering disorders, mucosal ulcers, leading to a wrongful diagnosis of diagnosis of ARS unless there is a the quite difficult angioedema on 3 separate occasions in the ED. high index of clinical suspicion for recently acquired The (primarily labial) mucositis was also quite Figures 1-3 Figures 1 and 3 showing numerous shallow erosions, some punched out, others with extensive, leading us to consider diagnoses such Iibhnous bases, affecting the inner labial mucosas, buccal mucosas, tongue, and posterior hard palate She has hemorrhagic crusted erosions of the lips with associated soft tissue swelling of the as SJS and severe HSV. Dermatologists should lips. Figure 2 (middle) shows a subtle morbitiform eruption on upper trunk and proximal arms. be aware that mucosal ulcerations are a helpful Case Presentation finding in ARS and can be fairly extensive. ARS A 67-year-old African American woman with history should be considered in the differential diagnosis significant for COPD. CHF. and HTN presented to the of mucosal ulcerations and rash, warranting HIV ED 3 limes within one week with complaints of painful, testing. even in patients without a known history. sloughing, ulcerations to her lips associated with severe lip swelling, sore throat, red eyes, and pmritic rash of her face and trunk that began a week ago after eating tropical fruit. Clinical impression each time was angioedema, and patient was repeatedly discharged with oral corticosteroids and antihistamines without References any improvement. On subsequent presentation. dermatology was consulted, at which time physical 1. Braun DL, Kouyos RD. Balmer B, Grube C. Weber exam revealed innumerable shallow and punched-out Gunthard HF Frequency and spectrum of erosions of the oral mucosa and associated soft tissue R. unexpected clinical manifestations of primary HIV-1 swelling as well as a morbilliform and petechial infection. C/in infect DEs 2015. doi: 10,1093/cid/civ398 eruption of the trunk and extremities. Differential 2 Cohen MS, Shaw GM. McMichael AJ Haynes BF diagnosis at that time included HSV. Stevens-Johnson Acute HIV-1 Infection. N EngI J Med 2011. 364 1943. syndrome, MIRM. atypical HFM or other viral etiology. 3. Daar ES, Pitcher CD. Hecht FM. Clinical Further history revealed she had not disclosed that and diagnosis of primary HIV-1 infection. she had an HIV positive fiancEe. HIV IgGAg/Ab presentation CurrOpin HIVAIDS 2008; 310 returned positive. Viral cx, [ISV PCR. mycoplasma 4 Pitcher CD, lien HC, Eron JJ Jr, et al, Brief but lgG/M, hepatitis screen were all negative. Lip biopsy efficient: acute HIV infection and the sexual was non-specific and did not show evidence of viral transmission of HIV J Infect Dis 2004; 189:1785. cytopathic change consistent with HSV. 5. Quinn TC. Acute primary HIV infection JAMA 199 Figure 4 close up view of Figure 5 More petechial eruption on 278:58. morbiliiform eruption on left arm and lower extremiiy suspicious for viral forearm. infection. I’

CASE REPORT IMAGING DISCUSSION

A 76 year old male non-diabetic former smoker with a PMH signiflcant for HTN, presented to an OSH with a 1 month history of back/flank pain and subjective fevers/chills and malaise. He denied any specific illness r when this started. Further work-up revealed blood V. -t cultures positive for group B streptococcus and a imaging with aortic ulceration and aneurysm with associated fat stranding. The patient was then transferred to St. Louis University hospital for further care. On arrival, the patient was found to be afebrile with a leukocytosis to 13.3. His exam was fairly unremarkable. He was started on IV antibiotics and cardiology was called in preparation to go to the operating room. He underwent a TEE and was found to have a mitral valve vegetation. He was considered high risk from cardiology to undergo open procedure. I

-... RESULTS Ch-EVAR is a feasible optionI for patients with mycotic aortic aneurysms given the morbidity and mortality of the hybrid cath lab. Both his The patient was taken to an open procedure. Ch-EVAR is achieved in a relatively The celiac and groins and right arm were prepped. shorter timeframe than FEVAR given that grafts either from above and supermesenteric arteries were selected have to be custom made or back table modified. stent were placed. From the self expanding covered Endovascular treatment compared to open showed a were selected and PTFE right groin both renal arteries decreased mortality rate of 9% vs 20-40%, as well as stents were placed. A thoracic self expanding covered an increased long term survival rate of 55% at 5 years used as the main body. The The patient continued to complain of pain even endograft component was vs 35%. Duration and antibiotic choice is still up for at the same time as the though the leukocytosis was resolving. He underwent main body was deployed debate. repeat aA six days after the first a, The ulceration and visceral stents. Final angiogram showed exclusion of the pseudoaneurysm were noted to have enlarged. He was aneurysm and no endoleak. REFERENCES continued on antibiotics and plan was for endovascular After the surgery he did well. He was discharged on 3— repair after the leukocytosis had resolved and blood POD3. He has had 2 follow up appointments since that U.(k?3l.I_.QT* r,.d32oI4.3fl3S—2i43 cultures were negative. time with a scans that show exclusion of the

aneurysm and no endoleak. l. 2032.39713323 333333333236.3333*20,1.3373711. ,4*lo 03.34.200., a I..346•-32, .3714.377*6473723 34 737*40. C21*0330 ft*jd 1117.167*43-3363

.0121 03133T6.02003*37L370 ft0.l*4l*l I*4...l2d,l201I07*. ———03— 37-I. WOfll* 63’ ‘7363917111’.

•13766bl67202’*.*4I,34l..M33,0 ....Ml3,Xr,-*437*I4*037I36j& 1.&’206.2a6441.*.*’7fl79014327-4L 6 29343202* — ______

Induction decreases vaginal birth after cesarean delivery (VBAC) success; does indication matter? Samantha J Mullan, MD, William M. Perez, MD. Laura K. Vncella, MD. Elena Kraus, MD. PhD. oUHIVERSIrT Renner, MD, GiladA. Gross, MD SAINT Louis Jennifer M. Jacobson. MD, MPH, Kathryn C. SSMHeoIL Saint Louis University School of Medicine, Department of Obstetrics, Gynecology, & Women’s Health Abstract Study Design Results Table 2— Maternal characteristics and obsletric history in women undergoing Objective: Vaginal b:rth after cesarean delivery (VBAC) is a proposed means of Retrospecoive cohort study TOLAC based on delivery indication — decreasing the cetarean delivery rate. There 5ev dense that induction decre ants the Jaariabtn tNt rledise toe) Post-dates (81) real inflation’s (I l3ijiateenal ledialionu tans) . chances of successfulVlAc however the effect of delivery indication in patients Inclusion criteria: Enclusion criteria “1 undergoing trial of labor afte rcesarean (TOLACI in unknown. We aimed to determine Hiutory of pri orcesarean delivery • Delivery under alweeks I 29)21-all whether VBA couccess after labor induction diftenaccording to delivery indication. Undergoirg induction of labor • Augmentation of labor (for advanced ceryical (eean( - 29 us.32r”f 25124-Ill za dilation) I Rant soon Study Design: Thin wasasingl n-center, retmspectiae cohort study of patients with a • Prematute rupture of membranes White 19)35 81 24 (2761 22(1951 42 fl995 h:ttoiy of prior cesare an delivery undergoing induction of labor- Eactusion criteiia Grouped into delivery indicatiots 51mb 59(55 II 54111.11 (13.21 149 (I0.6t ‘0-el included delivery c 37 weeks, augmentation of labot , and premeture vu ptute of • Elective H swan it I(09( 2 2.3) 5 (4 4( 00147) 0.3 membranes. f,sate’naland fecaldaca wetecoltecledincludir’grnatecnaldemographics • Post-dates (540 weeks) Ajax 0 2123) 5(241 63 and maternal ar4 neonatal cotcomes Data was ttratified into the fotowing induct:on • Fetal .r.dscatcovs(ron-reassunin g test:ng, 7166t 0(0.91 Sfa.4t Otwa I fetal indicationsfetal rodication (indodirg no n-reas surarg restriction, or o!:gohydsamnios) gttups: elective, pout-datet, fetal growth BMI tkg/rn9 It I2S-5) 30 126-mt 10 (23-351 - 1)11-391 I ndication testing fetal growtn resttinion, or otigohydramnios(, and maternati • Maternal indications (hypertension, diabetes ohstet,ie history (hypertenson or diabetes metlitus[ moflitus) Oh Fiiaseagieal delivery -— 4911621 3114251 5014421 I IoelsO.2l 05 r,in,tnAc -- nfa2nt 23(25.4) 30)253) 5212451 I Retail,: A total of 517 pa tients in Ihe study underwent labor induction foi TOIAC and Continuous’ krusbl-V,’a t;t less

. SI Piisia,inn . 12130.2) - 2111411 32l1L3l ha1294i mar inclus,cncr,:eria. There weresca tssticall’j s:gnifiaot dHerencesin iaceand Catoricat: Chl-nquareor F,sher’seract IM (92.t) Oil islsh?poaresS . 91)86 al 80(920( 200 l9-es gestational week at delivery p.0.05 and p<0.Ot, respectively). The gmu piwere Gentatinnal weebu 40 l3 a At 4) 41_n 14131.31 an a 139.3-41.11 n9 131.1-39.41 ‘0 01 —. similar WIth respect to age, bodf-maus indeu. prior vaginal delivery, prior VOAC and Compared VBACsoccess rates of each delivery (Table IDa. eesavna an wefun teerrawnln iaseulev N indication for priorcesarean delivery being arrest of dilation or descent 1). The indication to a composite poot of all onher ‘aiim ii nwdnueni.vaac nays utivumaieui I tMi - ssd,arnsodw,TILAC.waiuibbsrantnn san.eeasueinn .uam4 overall VBAC success rate for the cohortwas 63.2% range 6O.2-65.9%(. Th eve were indications no significant differenesin VBAC success rate between delivery indications Figure 1, Table 3—Maternal outcomes based on delivery indication in women undergoing p’D.S(. There were no sigt:ficant differences in macin. Ion neonatal composite TO LA C motb:dity and mortality between groupu (pnO.94 and p’0.75 for maternal and Va t isbies I N) Elective Itoh) Pont-date, (87) I fetal lisdiatioen lull) Matein.ll,d)catlann Ins, p neonatal composite, respectively[ Th erewe re no differencesi n uterine rupture Results I F Matenisal sampodle 25(595) 15(267) (905.81 4? (19-91 betweengr oups (prO aS). There were no diffet ences between induction mann mpt.te 1(05) 3 (2-fl 2 (0.8) 4 (1-91 indicati ons in cv La reans ectoss done for fetal indications or arrest cf dilation lemon2) Figure 1 — Rates of VBAC success based on delivery indication Ponipanlsehmnimthage at (07.0) 15 (11.2) IS (13.31 Ia 11521 or descrnt (P,OSG I. S land want tn)on 5 (II 31 7 tsl.nI 4(1 13 11 (11.11 ConclusIon: We found no significant ditferencesin rates of VBAC success between the I cesa reae hysterectomy Ito 91 1(1.11 1(091 2(0.91 indmt:on indicatiots. mete were also so d.fferetces in maternal or neorata 10 Matannal cu .dminsn 0 0 5 (0-tI 3(1.41 moib.d.tycr mortality, although the total numbewof indwidualostornrs tuchan L._..._,,J Maineil death 0 l(1l( 0 0 no usatine rupture wein law. Usa sea n lee NeC 10 IS 114)1 12 (II.)) Or (ISI 38 14.0

— I Lena teat (St cx re 59 84 (03 2( 15 (1) l 32 (59.6) - 3911831 Isaueuanvaef.,Nt%l — eeaeais.,ai. wenaoLan5 tries. uie aiim of d4atet Ot dewont to Iio eia. stint. lanai win

Table 4 — Neonatal outcomes based on delivery indication in women undergoing Background______4s ci labors I icr cenarean (TOLAC) isa proposed method of decreasing cesarean TO LA C 30 rlx.tist 8106) Pont-danes()7) felalindioanions(ll3( — N atessa I ledirations (2(0) p delivery rates. IvarlablesIN) Paeovaial sompssitr 13 lUll Is (12.61 19 (16.81 34)16.11 0.7 00 I

r 08 Cuitent factors known to affect VlkCsucceto accoedsngtn he Eunice Kennedf Shriver mis lppn I 5 (4.11 6 (6.91 5 l4-l 10)4.71 Mateinal Fetal Medcineonit, vetwoik Vffaccalrulatorfficlude: 80 rnxdanenl.leHc7 6(51) 1134) 011.8) 5(241 03 Age HIE sOil 1(t.l( 0 0 01 - Bodf-m assi r4es (BM1) Usaatioeated flioU adief 8(151 8(921 14 (0.41 28 ((3.3) 04 Petaien Mwndaand,e, Race scsi (alIt ,Neonalaldeath 0 2(2.31 0 I (0.6) 0-2 Any previous vaginal del.very or VBAC ,rwapiesaioenetN Delivery inadi caia,s (8) itd:caticn fcr priorce La rean as rest of d.iation ox descent -wim’ ,thn’-ionuis’u :caiissJ.emnatiJioeissaraiow* Gestational age at delvery

Hypnnensiuediueaa of pnrgnancy Table I — Odds of successful VBAC by delivery indication Conclusions Bishop score Labor induction In term women with S or 2 pri orcecarnan deliveries anemp tingi nduced labor an term, we found:

- 95% Ci Indication for delivery Odds Ratio . No obsecved dieerencesin yEA csuccess rates between delisery indications Understundltg effect ofdrlivery indicati onmaya low more informedcounselin gfor - —‘ No observed differences in maternal/neonatal morbidity and mortality, although overall numbers of women with a tow likelihood of sscceosful VOAC outcomes ouch as uterine rupture were low Elective indsction 1.37 0 .87’ 2 .16 Indication for inducnionof labor should not be considered contraindication to IDIAC

Objectives Post- dots, 1.00 o 62’S 61 References labor Primary Obctive: To detenmine ‘strtber VOAC success after induction d.ffem • Grobrnan WA et at. Development of a r,om.rani for o,’ed::icn of a vaginal birth after cenarean Fetal in dscationn 1.03 0.67-ISA according to de;nry indication. delwery obsrrr Geineco) 2007;109S06’12. Grobman WA coal. Does informat:on available atadmis nion for delivery impiose prediction olvaginal birth ya0bin&.tivna- Esamine the relationship between delivery indication and 55 a her oesaresn? Am’ Perinotol 2009;26)1o[693-700 m a:erral and neonatal ouccomes in those undnrgorng TrnAC. Maternal ‘4 cati Dns 0.5 0.56-1 tandon MB cc at. The MFMu cesavean Restry fa’’a-i affnct:rg ts enuccesn of tssal of labor after picivous 0 cc’’d:-nin’.en,l cetarean delivery. National lnst,taoe of child Heal:- rd Human Development Maternal’Feta? Medicine uniu

- indication is referenced to a control composed of all other inductions Netwoik. Am) oborer Gynecof 2005, 193-1016—r ______

Does gestational weight gain affect TOLAC success? Megan L. Lawlor, MD, William M. Perez, MD, Elena Kraus, MD, PhD, SAINT LOUIS UNIVERSITY Jenny JacobsCn, MD, MPH, Kate Renner MD, Laura K. Vricella, MD Sc toot or at aider SSMHeaILh Saint Louis University School of Medicine, Department of Obstetrics, Gynecology, & Women’s Health Absfract Objectives Results

Primary Obective: cesarean Objective A sours maternal obesity reduces the likelihood Of vaginal hnh after Describe relationship between VOAC success and gestatiosal we’flt gain in reference to 1DM guid&aoen, F gesoarisnal weight gain has )VDAC )s,.cces in published predictive models, the smpact of based on maternal pee-pregnancy DVI Maternal and Neonatal Outcomes F:--ivi.

- not bee, described The Instoute of Med;: ne (1DM) recommends targets fcrgeutational p. weight gain accordingto pre-pregnenry body mass index (DM1). We aimed to study VBAC secondary obiective: fl GWGIOM CWotaceedmg successin women who met or exceeded 1DM gestar;o9al weight eat guidesnes. Invesuigate relationship between gestational weight gain and maternal or neonatal oo.tom es following guidelines 1DM gudelines p-value Ne410f34%) To [AC Ns779(66%) trial of labor Study Design This was a retrospective cohort sts,xy of all women attempting Ma3enou5tns -. ahercesarean delvery (TOLAC) at an acadrm,: tertiary carei noination horn 20102016- :Ge:atoral age at detuery lweeksl 39 136—cS) 39138-401 0.07

Singleton, viable, nor.aronaalout plegrarcies 537 weeks were ,rsluded. Pre-ptegnancy Results UIe,.erre 10(3.3) 541.2) 0.93 - weight ant defined as la:t measured weight in the 6 months preceding p tegnarcy or the Pc::;artum hemorrhage 92(11.8) 65 ft5 91 0.047 earliest weigh in pregnancy before 14 weeks geStation. Delivery weight wan Gestat:otal diabetes 54(6.9) 26(63) 0.71 trecorded VDAC success comparinggestationgl weight gain recorded on admission for delivery. Women with tuta recorded pry-pregnancy or delivery Mood transfusion 29(11.9) 24(13.6) 0.42 weight were escluded. Geslationat weight gain acts the difference between delivery atd by 1CM guidelines I Maternal CII admission 3(0.4) 4(1.0) 0.20 clauuea pre pregearcyweights, The cohort was analyzed according to VBAC success. DM1 90 • Met 1DM a Euceeded 1CM rsarean hysterectomy 3(0.4) 4(10) 0.20 P03 were compared according to whether they met or etceeded M geutatsonal weight gain p,a 3rd Cr 4th degree laceration 14(2.4) 9(3.21 0.49 recommendations, Statistical anal yois incltded 4500g 44)5.6) $0112.2)

Clinical Presentation Discussion

mini with type diabetes mettus aerwea th the snergency 29 year old Dicorbonate vs. hlonpilsl Day Euglycensic Diabetic Ketoacido,i, department with nas4s&vomdsh.gldiarrhea and genenlized thdoeniinl pein of • Increased anion gap meta&& atidosis one thy duration He baa an insulin pump, but buys certain conponents kr • kesovwenia keecnos a las pimp off of Cn:gulist. He does not died. be blood glucose because be • Normal Mood glucose levels < 230 mgl& can’t afford test swaps.” O.tient follow’u with his PCP has been Enronsissent and he hasn’t been seen by en&crirvlogy ii several y’s. Hi. Mechanism of euglycemic diabetic kexoacidosist: average lwnsoglobin Alt over the past three years has hem, 93 There was a • Incensed urinary excres:oo ofgkrove due to escean coorter-regula:ory prewous admission liar OKA above 6 montha prior to presentation. honnones And mane likely. decreased hepatic production ol glucose during fasting

Initial Workup and Treatment ‘a So a type I diabetic patient.. Exposure to a triggering factor for OKA (infection, MI, scroke, etc) In the ED. n HR was lID. WBC of 233 SC of 346, initial bicarbonate patient + o(l6, bard reline ani on gap of 15. The ED also obtained a CT abdomen’pelvlt State of fasting while continuing regular insulin treatment (glycogen w/ contrast that was normal. 2 a 4 a 5 5 se II has long been depleted) Physical etam signitcauc for tachycardia. dry mucou, membrane,, and slightly + tender so palpation in all abdominal quadrants. Proposed mechanism that gluconeog enesis is Impaired In type I stases Per hoepital DKA proiccol. patient given IV fluids. IV insulin, and supplemental diabetica under fasting potassium until elecirolyses and blood glucose normalized, and anion gap 4 Blood Glucose vet. HoepsIal Day euglycemic closed. Patent’, OKA resolved within I 2 hosts of presentation and ens Excessive keeone body production in a state ennui toned so a sutcutaneo.au insulin rfliaien of Lanxso 20 U qhu and ax mcciu.m.dosc sliding scale Insulin with meals.

am Hospital_Course Existing case re ports oi eugl ycenis’c diabetic ketoacidosis: 21 ye F vi. TION on an insulin ponvp. bed not eaten Ia the pass 24 hours, HO I inaval presentation punnsa had scopeed working someone over the past two daysi. ‘a HD I AG closed, blood glucose normalized. Tranuisioned to ,thcaaneom insulin of Unius 20 U s and mediinn dose slidag scs!e insult’ with meal,. • 36 yo F Wi ha of alcoholism (IL of bnn& dali for years) prner.se-d ‘seth Tolcra org some pa intake. Nauscaivomitlng stiff prcicnt. epigautrk pain and I wtek of nausea/vomiong and poor pa intake. Besides Ian indications of severe pancreautis on CT, patieee was found to be in a HO 3: No pa intake disc entire day. Patient toll endorsissgssgnWicanc ketoacidotic state0 nausea/vomiting. HD 4. Resume dOS InNS @ 100 mt/hr and sorted scheduling anti.emetics. S?yo F wi hv of disbeses. noncompliant with insulin regimen over the past Patient continues to have nausea/vomiting wish very litde po intake. 4 5 6 7 week, was in usual state of health 2 days prior to presentation, came to wi altered nausea/vomiting, and abdominal pain. HO 5: Patient was able to mack on some crackers and water throughout the she ER mental status, iSueu w were positive for cocaine was day. Fluids changed to I.’2NS 100 mI/hr. Urine and serum drug screen and patient found so ben. euglycemic ketoacidotic utatei HO 6: Patient continues to vomit IV fluids continued. Cl consulted and started patient on aergi men of metoclopumide. and nosed patient’s continued n/v was most likely due to gastroparesis vs viral gasaoenserius. Final Treatment and Resolution HD 7 Bicarb dropped to a low of 9 that afternoon. Anion gap of IS. Kttoouria. Normal BC. Patient was placed on OS l/2NS 00 mIThr subcutaneous insulin was placed back on an insulin drip with I hr BC checks and a D5 I12NS infusion. His was switched back t oan insulin drip: and q I hr BC checks were reinstated. Patient q euglycemic diabetic ketoacidosi, began to resolve. HO 6. By morning, patients ani on pp had closeS OS I/INS was cont:tued © Conclusion 100 mLftsr se.’Ji qlhr BC checks Patient was snn,itioncd back iron, 5hz dr4s to Patient’s po intake increased signifscansly over the last two days of hospitalization as nausea subcutaneous insulat A high clinical index of susaicion is required to diagnose euglycemic diabctic rapidy improved. HO 9:05 IflNS was continued as wets as suite q?h, BC checks A, EGO and vomiting ketoacidosis. Knoeuledge ef the possible triggers of this condition in susceptible uhowed gastritis ‘ad esophagitis. Putient tolerated breakfast and lsnch without patieno will uemc so hastra diagnosis. At the same vine. other fonns of vamising. References ketoacidosis and causes of increased anion gap metabolic atidosis still need to be ruled out Once eugfyccmic d.abeoc kctoacidosss has been dugr.oned. the HO ID: Patient’s pa intake covsdsvaed to increase. VP were stopped. eu—at vune as. nina—ass sea. I’ 0th ti.ths.m. dahaw unwsidase.a varsea ana e,vwe.ve amine Euaueivemea. OasitH. ax ne’aa,ui,c flex snaunens is very sinaI., to the treatrner.t of DIck rapid rehydra’Jon using HO I Patient continued sa tolerate po intake without vomiting. Patient left in i an, intravenous fluids, and use o’ an insulin dip end an item erects fluid tontairhig sa004u.m, eeinvun.,s a.. mach hester and asked to leave. He was d seharged bter that eveni 2 °,aoel & c’aaOl sola h#vasea naW dexsroseun ol the anion and binresnavo eve k normalize. Eardr and Tin ins.,. se ham uen. Eezuoee Pesucee I nWa, I. gap liii 5 listS sf aggressive management will minimize morbid ry and mortality. 2 ia.A. use’, Ii aittis 425515 air Sites bnssnk,an, Case tniiu.u ceeusicue aol, anal. in’ voossi Cl t 020 it in °sili • F.! ,,

Assessment of the Healthcare Literacy of Mohs Micrographic Surgery Pati Duprey C, Armbrecht E. Sehshad R SAINT LOUIS ) U N lYE R S IT Y. St. Louis University. St Louit. SO USA % Oi:rAwt sit ,-ml cit — lit,.,. — lit KM ATOI.OOY L

Background Results Conclusions distributed, 92 completed (78%). N=118 surveys • 31.5% of patients identified as potentially having • There are a number of factors which affect Demographics: I limited literacy (9 8% had high likelihood). palient compliance Compliance issues with r• Average I med)an age: 556/66.5 treatment regimens can lead to frustration (or • Race: 98.9% white. towards higher average scores with both the patient and the physician. • Trend • Language: 100% listed English as primary increasing levels of education. • One of the most important factors in language. Not quite statistically significant and education determining patient adherence is the ability to • Education: 283% high school. 18.5% some not necessarily predictive of literacy (some understand and follow instructions. college. 31.5% 4-year degree. 2 1.7% graduate patients with high education had low literacy and Additionalty. lower levels of healthcare literacy degree vice versa). among patients is associated with decreased • Housing: 22 8% rural, 53.3% suburban. 23.9% patient parlicipation in the healthcare decision- urban. • There was an association between increasing age and risk of limited healthcare literacy. making process. • There was no association between the area in which a patient lived and their score. • The consequence of this is decreased palient • Our results closely model those of the 2003 satisiaction and worse patient outcomes. This National Assessment of Adult Healthcare Literacy. represents a significant obstacle in providing • Theirs: 36% identified as having basic or below- optimal patient care. basic literacy • Ours: —32% identified as potential or high risk of • Physicians accurate assessment of their limited literacy patient population’s healthcare literacy is communication. critical to ensuring effective • We should pay special attention to at-risk patients and patient participation, patient compliance, and rethink how we communicate with them. optimal patient outcomes. References I Ryan JO, Leouen F. Weiss SD, Aibriry S. Veiez S. Sabbi N. Oo lo having their i’ieraty skills dinicai • 9.8% of patients demonstrated a titgh risk of oatienis obiect assessed in practice? Health Educalion Research 2007 tin press). limited literacy. 2 Cutiti CC, fleenett IM. Understanding the Health Literacy ot • 20.7% of patients were identified as potentially America Resutts or the National Assessment ot Adult Literacy. Methods Oflhaedic nursing I Nat,onai Assooalion of Odhopeedic having limited literacy Nurses. 2009:28f11 27-34 3.Nalional Assessment ofAdull Literacy’ Health Literacy (RB-approved survey. Res*s. https:ttnces ed oovtnaatmeatth resutts asp 4.MartAi IR. ams a, Hasksd KB OiMatleo MR The • We selected the Newest Vital Sign survey as it r daats,o of oaerg a&lerence. Therapeutics and Clinical Risk has been previously vetted in a number oi Manaoeanenl. 25:l(3).189-l99. 5.Christfla yR. Qiuaoo DJ. Lee 81 Assessment or Patient studies icr its ability to measure healthcare Health Lkefacv A Nalional 5mev of Plastic Surgeons. literacy in —5 minutes. Plastic and Rewesbvrl:ve S.toetv. 2014 Dec;134(6t1405- 14. 51mb 10. West B Bra mrnemr K Savw-Moore RI Health • Over 8 weeks (Feb — Mar 2018), the Newest Iteracy lestrutneel iti Lot met: the newest vital sigrr Vitat Sign survey was administered by our ease of see and tour ons. JomxTtal of the American Board ot nursing staff lo Mohs micrographic surgery Famfy Memo. 2o1rt,r.Aar23I2).1952O3 Rnr,G S. Saad S. Rachma!e The survey was conducted Patti PJ1. Joel S. Peseddy patients. P. Shukla M. Deol :trioo L. Testing the utfity of the immediately abe, each patient had their 1st newest vital slpr ii.J[,’i’”i literacy assessment toot in Mohs layer taken • There was an association between education and older Afncan-i’.’i, ‘jjz’. Patient Education and health literacy. • There v/as an association between age and health counseling. ..“‘

. .‘ l.l ,.lNri’,’r t oh Q.FfrAsessment score literacy scores. 6 Weiss BD r.’’ ot • Patients also wera asked to provide limited Patients with more education tended to ‘ Literacy in P ør’. Th il’ni’”t ‘Jut

Perianal Plaques In a Five-Month Old Infant 2/ SAINT LOUI S soic UNIV ER SIT Y Kesha Baxi, DO (Pediatrics PGY-2); Lisa Akiyama, MD (Pediatric Neurology PGY-3) Faculty Contributors: Dr. Elaine Siegfried (Pediatric Dermatology); Dr. Aaron Miller (Pediatric Infectious Disease) CIaIGlennon Hospital St. Louis University-Cardinal Glennon Children’s Hospital Children’s Introduction Inpatient Evaluation Discussion of congenital increased 38% between 2012-2014 Up 1030% of patients seen in pediatnc clinics have a skin-related complaint.’ In • Labs: The rate syphilis cases in the US 3)5 I of infection many cases, history and skin exam is sufficient to establish a diagnosis and COC: WBC 25.9(8% N: 67% L. 4% C, 14% Atypical). HgblHct gI2g; MCV (Figure This rapid increase minors the rise this in women.3 tn women increased 420% recommend Ireatment. The ditferential diagnosis of skin lesions presenting in 70. ptalelets 341K Saint Louis fSTL) County. the incidence of syphilis in between 2011 and 2017 (from 1.0 case to 4.g cases per 100,000 women). 88% of infancy is different than other age groups. Although the decision to pursue — CMP unremarkabln these female cases were diageosed in women of childbearing ago. In 2017. three additional evaluation in infants is heavily impacted by Ihe need for invasive tests, in - UA. normal infants in a some cases, invasive sassing is indicated to prevent disease sequetae. • Additional evaluation yielded lovi suspicion of sexual abuse cases of congenital syphilis were diagnosed among hem STL. resurgence after the last reporfed case in 2052. Standard-cl-care includes one nonireponemal RPR) for syphilis during the first prenatal Vsiflls1intrniusr iFlh1l screening lest (VDRL or cost-effective, quick, and can provide good marker Case History •‘—‘ c.,_wes visit.6 This type ol lost is very a for therapeutic response. However the tests with more specificity or Ihe A f.ve-month old term male n’ant was seen in on cutpatient clinic for a (em Firorescere eoponema( fgG Reactive conflonatory tests are the trcpcr’iemal tests (such as FTA’ABS or 7 patiiiurn month Ftstoq of graduaSy enlarging, triable, penanal tes:ons. antibod; ateo$ion teal enzyme immunoassay).’ As evidenced by 0-ar case, the one t:me screening The lesions Ia led to iniproved alter an empiric course of nystatin ontmenL The approach may tail to detect the infection. patient had received no other medications. HiV4nndy.p24antigen Nrst.’,e

- [vamwwn Soj The rr.ajnnity of neonates with congenital syphilis (up to 90%) are asymplomauc not have suggestive signs on newborn exam. Early signs of congenital H.d US and rear syphilis typicalty appear before the age of two and include: coodyloma lata, ,ga$eof&E .:.( hepafomegaly. jsund-ce. nasal discharge (snuffles). rash, generalized tymchadencpatriy. ar,d skeletal abaonna!.lies (e.g. diaphyseal petiostitis on long bone radiographs). Other manifesfahoes include pneumon:a and ophthaLmologic abnormalities (such as loss of eyebrows or d-.ohoretinLlis). cras syphilis is rare ama fypca:ly man:fests between 3-6 months of age as emees, bulging loe:aeelte, and increased head ciicumference, CSF fli’rdiings would show vedorninaace of mononuclear cells with increased profen and normal g&Jcose.’

Figure I: Peers rasiws seen at We Pediatnt or, ‘..i,.tlr ‘-vuate,, This case illustrates the value of consultation with pediatric subspecialtsts • He was referred to Pediatric Dermatology for further evaluation. At that lime, pediatric dermatology for atypical skin lesions that do not improve or resolve thinorthea was noted. A punch biopsy wss pedorrned. Histologic features following recommended treatment (especially in infaitts wttn are not otherwise prompted Intectious Diseases consultation and hospitalization. healthy and grewieg well). and pudiatnc infectious diseases for diagnosis and • Fast Medical History management ot unusual suspected and conftmed iefect:ons. • Born SGA at 38e2d via NSVD to a 24 year old mottier • Ibm had remota history of gonorrhea and chlamydia for which she was treated, Antenatat screening tests for HIV and syphilis (RPR) were

negative. caun P55 55. a,, iN.tOO egm,”I • Infant exposure was detected in mecoefum and urine. Metabolic marijuana I screen was unremadsabte. The patient was discharged from the newborn — Cs Saran nursery at day 0t life 2. rev See ‘an • His immunizations were up to dale • Social: The patient was noted to live at home with his parents and 2 siblings, Figure 2, Femwai fla,n F,ias Leit ti urd Rbt nit He was occasionatty cared for by his maternal gtandmother. • Farnity History sickle cell trait in mother and lather. Diagnosis ‘to • Differential diagnosis br these perianal lesions includes complications lrom Physical Examination diaper dermatitis (e.g. Jacquet’a erosive diaper dermatias: pseudomervouam • General: alert, calm, no distress papules and nodjles. granutoma gluteale i.nfantun). Lar.gemans cell aq Nil flit fl’2 Nil Nil Nit rote air • HEEN7 anterior tor,taneltes open arc Vat. Oropbarynx clear. No cervical. histioc1nsia, HPV. HSV molluscarn. and condytomata bla. asifary, or nyu nat LAD. neck supple. Flat nasal bndqe. - A punch biopsy conf.naed caldatma tata. • Respiratory CTAB, no distress - The presentat;on was much mom supportive of early congenital than acquired Figure 3: 01)0 Ceegersai Sea. Cases • Cardiac RISR, no murmur syphlis. • Abdomen soft, normacuve bowel soenes, no HSM A 10 day course of IV penisitin was initiated per evtdence.based • GU: normal penis, perianal region with flat topped, flesh colored papules recommendations°. coalesced into a rubbery sessae plaque involving the penanat mucosa (Fig.l). Pananat tescos cleared sign:ficantly a’tcr 10 days ot treatment. Sk:n: no jaundice no rash on palms or soles, no bieed:eg noted A4’fold pest-Ireatmeni reduction in RPR titer (1.256 to 116) served as • Neoro. symmetrical fades, PERRL. moves at exlrem:l.es. nonral tone evaenca of core.

F,e,ud liejis, fl, j. 101 C C 20*55 FusSes Desy — n_ag — han Pusa Oer N ,2r ,.ut ,o.giIt,n. , I, igutaM UT. .aaa. sue, Le’g (aura rOta patdw* - - “ Aws,0, Des * C - F , 55 - —i ).fldP ate - . -- -. — k a 4 A a a,. NM *3 Suuuuu a frdcav.S4 s,fl . s—a 2052- — : . - - -‘ ‘j 4t5& aa b.aiue.sMs-xu.Lmruo.. earadaa N11M tMn’i - , . - • .5 - a , . — s._u.uei.ar R.m 115351 srnua.r. :atenyorwunsrinop

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Nonoperative management of acute appendicitis is associated with increased ality Christopher B. Horn. MD.’ Dajun han. MS.2 Grant V. Bochicchio, MD. MPH.3 Isaiah R. Tumbull. MD. PhD3 1. Department of Surgen-. St. Louis University 2. Institute for Intbrmatics. Washington University in St. Louis 3. Department of Surgenc Washington University in St. Louis Background: Results: Results: • Appendicitis is the most common • 477,680 cases of appendicitis were identified In logistic regression, nonoperative management is associated with increased mortality indication for emergent surgery • There is a significant trend increased in • In recent years prospective trials have nonoperative management (2.3% vs 4.9% in I OR tar PPer IiE! 10531 1.04’ — 92 - 2014, pcOOl) — demonstrated the feasibilit of a non- f-E- j’_3L._ 3:034. African AmeHcan 2 023. operative approach E - tissic - — There has been no large scale analysis of rA0 or Padf,cI,lan tier 1.891 • — 43Z5 3: - l.3ol; .033, OS ,atktAn.edcin - L.her .136. 2.93’ 48:

of — outcomes - practice and associated Unknrn,n - .323 e; - 53 , appendicitis (Moo- Appendicitis ‘sib pernoniti., I

MOO Anile appendicilk ‘ibm, ii rnlk n of - .36: —49: el peñl.nhIi 5) .519

Methods: N MI (Appendidlin, UqalI(8d) j f - , 4281 • National inpatient sample (NIS) from 1998- a :542l2frfl’lIril’. .7711 .t63t__.3 qj°._rja, Gymphod oiaendij,, lsis.o hyperpiasia Of”” 01 o 2014 queried for cases of appendicitis ofappendn) 5439 (Other disease .39 .051 2.93j .3641 • Cases with associated abscesses, elective - Number of Oiaowses ni6. ,.2 00li LoSh - 0iJ__°S, - p53, c3J admissions, minors excluded [ppperalke fl935rnent - 2.133. _L331._. 3:668: • After case-matching. nO differences in • Elixhauser/van Walraven comorhitv indices 1008 2003 2002 2004 2000 2000 2010 2012 2014 demographics (data not shown) applied — Fail0 Operason — Ope’alson then Dronoge non-operatively had increased — Na 5*rneeOon — Oae,a)a the, Oparit,on • Patients managed • Trends in management ofappendicitis in — Oeaynd Operan — Oranage O

öj1 Eii_o — nonoperative management of appendicitis • Multivariate logistic regression used to Nonoperative management is more common - • identitv predictors of mortalit i31162 4694 Age 49° in older, sicker patients • Case matching preformed on all 40.9 (t6.9 li • Nonoperative management remains an Appendicitis with I 1574 independent predictors and outcomes of 26193(20.0%)- <.0011 peritonitis independent predictor of mortality aIkr compared I ---. (aa5-). logistic regression and ease matching

Elixloauser/van - .78 (1.64) <.001. -Walmven (1.18):_1.35

• ‘sNian UNIVERSUY UnKersity in StInEs ____

Altered Vaginal Cytokine Expression in Patient’s Receiving Pessary for Treatment of Shod Cervix( 0 JenniferGoldkamp M.D., Alexandra Edwards M.D., David Kraus M.D., Gary Fwhman M.D Gil Gross M.D.- RajeevAurora Ph.D. SAINT LOUIS UNIVERSITY Saint Louis University School of Medicine, Department of Obstetrics. Gynecology. & Women’s Health, Molecufar Microbiology and Immunology SSMHeaICh Abstract Results Results Figure Microbiome diversity Objective: vaginal pesnarles are a treatment for gravid patients with short 3. cervix. Increased dxcharge has be aconsi otest f.nd rg In multiple pracr Table 1. Demograph ics and Outcomes invext-gat,ons ar.d it’s etiology has not beer. exeidated. We aimed to explore — — 3398_ boa variation in ryto kineen pressaon following placement of a vaginal pessary in Age Race Race Tobacco UMI Parity Prior P18 Delivery Birth weight w.ths hort funneled cervix. We hypothesize that the cytokine patients (mean) (AA) (White) use (avg.) (avg.) GA (gm) expression profle altered a sacotseque r.ce tf pessaiy use. (pwO.OOI) (pa0.05) = 4695) Study Design: This isa prospective cohort study of pat. ents who rece red 10, 5, 26% 29 0.4 0.4 34.4 2324 lu Inflatobat pessxr:es fcr shortened cervia C entatrona I age-matched Pessary 25.8 - _‘u-SIUI Milex U518S — group. Fo!lowing consists without cervical shcrten-rg served as the control Group 66% 33% lontrol content. pensary group atd corsiol palientx underwent collect,o nc-f perle (U : 5355) vaginal bvag, for baseline npecim.n. Soltatrns were foSowed longitudinauiy (16) and underwent vaginal lavage collection a week later and then 4200 2124 monthly. Msltipleeed EUSA analyzed 35 cytobines with a broad survey panel Control 27.8 7, 4, 27% 35 2 - — 0.3 37.0 2822 Cytokire tevels were compared longitsdinally wifhin eacharm.brlween baseline eaperi menial sabiectsandconlrols. Longitudinal cytokine (11) 63% 36% Total number or luimique) OFU across MI 4 wIn. foil. (sm,i,iii of all tour groups) concentration was corn pared between the two arms. Pair-wise comparisons Figure 1. Microbiome dominance were performed us:ng Mann-whitney U test. .-r —PeIt.Pessaee —Pie-Ceat,.i Possicoxtid Results: Moss of the 32 cytokinenwere below the level of detection. Granulocyle-col onystimu lating factor lG-CSP) demonstrated significant Summary differences between pre- and poss-pesnary arm and poss-pessary arm pc.0005) and baseline penury arm and baseline control arm pc.0003). • Cytokine analysis: lnterlesk,s-4 IL-a) likewise was ii gnificanlly dilletent between baseline - 3 comparison eroups: fpv.O0S) post-pessary arms (<.0001). ‘p specimens in each arm and pro- and • Pre-pessary short cervix vs baseline control: Inierleukin- Sw’s en piessed differenilfin pie- and post-pessary arms IL-ia and GCSF were reduced in women wnth short cervix at pc 0001) baseline pessary and baseline cons, ol alms (p.0105) and longitudinal Pensary and conbol arrr.s (pa 0001). ln:erleutin-1-a (IL-i-al was baseline relative to controfs variably expressed between baiel:re arms (pa 0005). - Pre-pesnary short cervix vs post pentary short cervix - IL-A, 1-6 and IP1O (also called CXC3) were upregulased post Conclusion: nfnif.cantvariat:on in cyloLne a pnession wan noted in pessary 0 xn.. pessary (allergic response) patients compared wilh controls for G-cSF, It.-,. IL-b. and IL-i-a. Redi.ced - Post pessary short cervix vs follow Up control cytskne ea piession of IL-i alpha and O-CSF are noted in patients who underwent pessary plate-ness. However IL-S is higher in oreterm patients • Microbiome analysis: relative no gestational age-matched controls. Alteration In rytokise • 3 comparIson groups: eaovettsn follow,ng pessary placement in grasod paliests is eupected, ‘4 control: howevei, the allergy-like response is surplisi ng. Additionally, the reduced • Pee-pessary short cervis vs baseline immrne response pnior so pessary piacement itanl I. rdirg. • Laciobacillus is the dominant phylum in all samples but she quantity in women undergoing pessary placement was Figure 2. Cytoklne levels decreased Study Design 0-CSF • There was more heterogeneity in the women Undergoing pessary placement Prospective cohort IL-S Inclusion: Il—I • Pre-pessaiy short cervix vs post pessary short cervix Singleton + short cervix + having penoary placed 00035 - Post pessary short cervix vs follow up control • Gestalional age matched controls - Alter pessary plscemenr, heterogeneity appears more 2500 Exclusion: active vaginal infection similar to controls Collection: • Samples were collected by lavage and swab of vagina 3 ‘sos - Trichomonas was present in many of the short celvie group prior to pessary and approtimately I month after pessary placement is r’ pie Pwa ‘re Post Pie pie. - The lavage and swabs were frozen and slored at -bC Pm P50 CPessaryj Lcnxaj c J L -esa J Conclusions analsiz Pnary bteuibtwn rapidly in then spun at IP-It • Samples were thawed 37C and 1L3 pus • Women with a short cervix have bandine diffeirnces in cytokine 15k t for 15 minutes IL-I alpha expression and mscrobiomevs. gestasional age matched controls • Cytokinet my multiplexed ELISA (32 plex) and C I =° a • Reduced cytokine expression of IL-la and GCSF is noted in women wish microbiome analysis. F” a short cervix • pgry4nalsin:Mann-Whitney U. (hi-squared and independent C - Following pectary placement, differences in cytokine expression can be samples T-test a we- detected which previously were assocaated wslh allei5ic response - 3 comparison groups: 0 0::)- - Following pessary placemert changes in the microbiome in women cervix vs baseline coninol • Pre-pexoary short wilh a short cervix xpproei-: des controls • Pre-pessary shorn cs--s’s pots pessary short cervix Is, p ry./ [*i-- I • Post pessary shoi - ei Sn follow up control em .resa—i.-C-i-ci pen, me em Penary lass,:? LPww3J LcaeeJ Sikifr IExpresslon of a-Synuclein Ifl the Dysplastlc Neurons of Pediatric Conventional Gangliogliomas; a Diagnostic Tool in Challenging Cases ,!t4t—at4t -‘I Alyssa Higgins DO, Miguel Guzman MD Elizabeth Davaro MD, SAINT LOUIS Department of Pathology, Saint Louis University School of Medicine, St. Louis, MO UNIVERSITY — ES’. SmI — Background Results Discussion & Key Points 3— ,Lt AIpbas)nucleJn fntiwceln) showed universal • of a-synuciein nearly • - • a • •.‘.-, —. ‘•‘ —‘ —— - —— • Immunorcactivity • Pro-synaptic cytoplasmic protein found abundantly in neural tissue • -D positivity within the classic gangiiogliomas tested 1 •r.: i • Coincidentally, synaptophysin, known to show cytopiasmic - ‘ J • /1 • Highlighted cytoplasm of dysmorphic ganglion cells (>5% vesicles positivity in gangliogliDmas, is located in synaptic %_ S ,,.,, -, . g,. lesional cells) in 18 of 19 cases • While function remains unknown, possible role in synaptic ,,: -‘‘‘ .;‘- •‘: :.“—- •-‘.. ‘- , - in our study, there was a statistically significant association . -. plasticity & memory (syneif in: avian homologue that modulates • •-t. •. :‘ - male zebra-finches) between positivity of asynucieln immunohistochemistry song-learning circuit of juvenile ‘‘ ,.;.“t: .— • -- • Widely known for its presence in neurodegenerative disorders • 0 1 . and a dIagnosis of classic ganglloglioma with a sensitivity r. •, • • of inflomas •t? of 94.7% and specificity 95.2% • Benign (WHO grade I) glioneuronal tumors of the central nervous . • Pearson chi-square testing was used to assess • !‘t” . E O’ the association between the positivily of a-synuclein system (CNS) characterized by dysplastic ganglion cells and ,.-.:‘ s... .1Jc;’ * and ganglioglioma diagnosis neoplastic glial components -• ,1• ‘ -L•’- • Have been described to exhibit neurodegenerative findings •... • ç. “:- • p-values cO.05 were considered statistically significant • Can be challenging to distinguish conventional gangliogliomas i ?>,, lot 1 SEGA was also positive from tumors with ganglioneuronal differentiation • SEGAs show glioneuronai dilferentiation •- • Highlighted by recent recategorization of classic ganglioglinmas 1 • Some consider subependymal giant cell fumor (SEGT) :‘- . . and pilocytic astrocylomas with gangliocytic differentiation gh; a more appropriate name given the tumor’s mixed ,- •:*‘ • Distinctive immunostaining is therefore essential for definitive phenotype FtgeI: Demonstrates H&E 0 and a-synuciein immuooi:s’-:-.snicai staini’g (B. c. C Ir cases (case identification t A. B: case 2: CE of classic gangliogliomas. Dysplaslic neurons 0,0 b:nucleation ai arrow - :5 Cytoplasmic a -synuclein was negative in the 20 other We hypothesize that asynudifin expression can be used to siaVng pattern charactenstic ofa-syriuclein in class-ai gangtc-giiona. Staitereil sttr ‘. can neoplasms and processes tested. highlight dysmorphlc neurons present In classic gangllogllomas aN: be seen WI neurites. Staining within neurites of pilocytic astrocytomas, and thus aid In the diagnosis of challenging cases gangiiogliomas. and SEGA - • While the positive ratio of a-synuciein immunoreactivity Design within gangliogliomas is not as high as that of a-Synuclein stain was performed on a retrospective cohort of CNS synaptopiiysin, this study suggests o-synuclein may show entities diagnosed at our institution: a higher positive ratio than studies have demonstrated for • 19 classic gangliogliomas (study group) either neurofilament or chromogranin A. • 6 pilocytic astrocytomas • 1 dysombryoplastic neuroepithelial tumor (DNET) Conclusion • 1 aiypicol extraventricular neurocyloma Demonstrates that a.synucieln Is a useful neuronai marker, extra tool • 1 subependymal giant cell astrocytonia (SEGA) nan: H&E and may give the pathologist an (to be used in 1 case of cortical dysplasia lAl & U addition to the established IHO panel) to assist In challenging • S cases of reactive gliosis S5Duciein B cases, helping to distinguish gangiiogiinmas from asliocytfc • 3 cases of astrocytoma. WHO grade II derived neopiasms cytoplasmic Specimens were examined for eligibility, & stained with human RfiifeZ CysemboØastic neuroepitheiial tumor positiviy in this aipha-synuclein Ab-2 icione syn2ll. 1/250. Tnermo Scientific, MS-1572i. A yccT B is compieteiy negaive for u-synuciein a cohort from another subependymal Future aims: validation of our findings in I (B:. o-Synuciein espression only blinded evaluation was performed independently by two reviewers. appears in grant cell institution; additional study utilizing an increased number of occasional neurites in this case of p:cc4t Cytepiasmic asynuci&n stainIng in ‘5% of iesionai cells was asirocylorsa. low grade ghoneuronal tumors and pilocytic astrocytomas with astrocyloma iC. Di. 5’; consIdered positIve . ganglioglionai differentiation, ______

Introduction Results Discussion • Noon conference is a vital educational Resident Free Responses to Improving Noon-Conferences • Attendance and interest in noon conference opportunity for our residents Word cloud diagrams show the rclst; a frejency of words used in the comments of the survey. Larger have improved following our interventions words were used more often a Patient care, pages during conference, and long a Conferences were poorly attended, and resident Pro-Survey 6 Month Survey satisfaction was low rounds remain top barriers to attending • Surveys showed top barriers to attending conference conference included: Attendings are not holding pagers during • Patient care obligations conference • Pages during conference a Comments from the surveys reveal continued • Prolonged rounds desire for attending engagement, relief from • We designed a multi-pronged approach to pages, and a diversity of topical content improving the quality and participation in noon conference Conclusion Pecentage ofResIdec.sAttending Percentage of Residents Who Want Methods >60% of Noon Conferences to Attend SLU Noon Conference • Limitations: • Pending End of The Year Post-Survey Participants Goals Data Data • Minimal participation in surveys by 45% • Internal Identify • Pre-Survey PGY-2 Barriers n ns Medicine • 6 Month 0% I a’ • Low 6-Month Survey Response rate; • Residents Establish -hafl, Sn,y and 1 Year b ‘W sib 5’j,v resident survey fatigue? attendance Post- a Need to strategize noon-conference goals expectations Survey Resident Survey Responses • Need to combine expectations of residents and Pre$uwey S Month Post- Question attendings Survey a By focusing conferences to resident interest, we I attended 64% 96W Interventions During inpatient rotations may improve enthusiasm and engagement noon-conference 60% of the time or • Faculty Expectations more* • Complete daily rounds by 11:30AM When I am at SLUH, I want to go to 58% 83% • Hold resident pagers during noon.conference* 53%* Future Directives conference During noon conference at SLUM, the 47% • Residents speaker keeps my attention • Attending buy-in • Tracked attendance I feel guilty when I do not go to noon- 61% 69% • Attending noon conference page • Provided lunch at conference daily conference reminders • Conference Quality When I am on service at SLUH more 58% 86%* • Affirm rounding-end times • Reports emphasized clinical reasoning than 40% of the attendings encourage • Encourage attending attendance • New High-Value Care series me to go to conference • Utilize noon conference evaluations to improve • New SLU Case Series conference Resident and intern Report occur 58% 72% conference • Revived Journal Club frequently enough at SLUH dpnntpc craict, OP ;prnpfpranrp nine SOS Higher purpose Greater good” -

Introduction Pertinent Images Differential Diagnosis 1. Anatomical varants (Peclinate muscles. Crista terminalis. Pericardiat cysts (fat. The differential is veiy broad in a patient with bacleremia and Right atrial mass Mitral annular calcification, Atrial septat aneurysm) on Echocardiography. The patient had a routine endovascutar workup with Implanted devies (Pacemaker iCardioverter-defibritlator leads, Right heart TrE, TEE. CT chest abdomen and pelvis, daily btood cultt.res and cultures of 2. Prosthetic vatveslclips. Foreign bodies) the catheter tip when removed, However, the index of suspicion loran catheters, Occluder devices, endovascular source of infection helped in diagnosing a rare yet possibly fatal 3. Thrombus condition if undiagnosed. 4. Vegetations 5. Tumors (Pnmary, Metastatic) Case Presentation 6. Mitacts

- 55 year.old male presented to MICU with fever, abdonwsai pain and septic Figure IA and B: Discussion shock due to Staph epidernildis bacteremia. He was hypozic arid was TEE show:ng a very large pedunculated right atriai mass allached to the atral wall intubated. Lactic 6.4, Cr 1.4 WBC 48.5 (Abs N 024.1,99%). pro caicitonin near IVC and BA junction (254 x 2.43 cm). Mass has ntbite projections rars,ng a 351 He was started on vancomycin cefepkne and fiagyt ‘nlh levcphed and .03 for high risk of embolization. Throm,bus formation is less conyntn in the right compared with the left atrium. ste’iifs Artib:olics were later switched to Vancomyhn, Meropenem and L°’’p It occvrs in association seth in’dw&hing catiwtefs, especially al the jur.cticn of ktcatur.: superior vena cave and r.ght atrium. for P1CC 410 was ‘emcved and sent for cbthxa wNch came back pcstive Thrombi also can form in the right atr,al appendage in patients with atilal fibrillation Staph epkterrnidis. After removal of line, baderemia resolved. Deescalated or pmthmmbotic states although it is less likely site for thrombus formation. therapy and discontinued Piperacitlin Tazobadam and Micafungin and Among patients with Athal Fibrillation, right akial appendage thrombi occur in 3-6 continued on vancomycin. percent of cases compared with 13 percent with left atrial lhromb,. • Other predisposing conditions are tricuspid stenosis or prosthetic tricuspid valve. Physical Examination: • The majority of patients with right atrtal thromb, also have left atnal thrombt. There was a PtCC tine and a suprapubic catheter in place at admission. The Pulmonary emboli can rarely be imaged in transit or entrapped within right atrium. rest of the physical examination was benign. • On occasion, an embolus will become enmeshed in the foian,en ovale as it paradomicatly passes from right atnum to left atrium. Workup; • Otood cultures and catheter tip grew Staph eptdermdis. lYE showed no vegetation bul incidental RA mass measunng 1 .9 x 3.Sail. confinned on TEE Conclusion • Subsequent blood cuhures remained negative. carc.d duplex showed no significant obshuct:ve lesions or • Vascular Our patiert improved drsm.aticafly after removal :t r,rmht ethel tomes. Broad seen right toternal ugular vein, stenosis. Non-occlusive thrombus in guro2: spectrum antibiotics were narrowed to one week of I-i Natc-i;-n fortransient negative for pulmonary enbofus. • CT anglo PE Right atriel mass removed by bacterema with Staph ep.dermidis. There was no evidence of endocardilis on CT Chest Abdomen Petv.s showed no abscess or septic emboti. cardiothoracic surgery and - TEE. The leutocylosas aid fevers resolved after surgery. begn. • Panomx was issue sent Fm Fistopathology The leach rig point ts that though abel lhrombi am rare, it is mpoqtanl to took for • Jhne cuiture nfl growth. was and cultures to nile out atr:al t.oem as a pcssib!e source of bacleremia and also lot lhe complication of [yxoma. pulmonary embolism associated with large atnal thromb,. They are associated Course of Illness: seilh indeetling catheters and our patient had a P1CC line in place and had a right surgery removed the right athat mass and placed Four chest Cardiothoracic Internal Jugular Thrombus on Carotid kiery Doppler. He had a timely diagnosis of tubes midtine. Tissue sent for pathology and cultures. After few days all and lJ the thrombus and thus had a benign clinical course. Ills also pertinent to removed. Fever de’eftervesced and white count came back ‘Figure 4: chest tubes were remember that final diagnosis hinges on Histopathology of the mass. to normal. Pathology finalized the tissue sent as ‘organized thrombus”. - Microscopic view showing no lumor cells or pathogens but an organIzed ‘Figure 3: busl Treatment: Right atrial mass (gross specimen). References Patient completed recommended duration of appropriate thotapy for Staph epidermidis bacteremia with Vancomycin for 7 days. I. Panidis P Koter MN. f.’inlz OS Ross J. Clinical and echocardiographic fealures Past Medrcel History: of righl sinaI masses. Ass Heart i. 1984.1o714):745—75a. IEMQed H.rN 12- ncress,ve Disorder with sLicidal ideation. 2. Ogren M, Berg;v.st 9 Edksson H, lindblad B. Sleety NH. Prevalence aid risk Crchr;;:r:zc(wthfrequentftares,2porrnonthsfp7bowelresedons). of pulmonary enthot) rn in patients with lotracatac throrrtosms: a population-based One m:-ntb ;:. Crohn’s flare was treated with imuran. stelera prednisone study of 23796 consecutive autops.es Eta’ Heat J. 2c05,26(t1):11D8—111& and stan: on TPNINPO and P1CC tine placed, 3. Bashir M Asher CR, Garcia Mi. Abdafla I Jasper SE Murray RD. Grimm BA. Right athal echo cootrast and thromb: in athal Uretf;m - stnrrre since bulb (sip imiliple trethroplasty. suprapubic cethcter Thomas JD Klein AL. spontaneous in DIsc. ‘r:r last 3 months, last changed one month ago by his Urologist ftdilaLion: a Uar.soso-hageal ecttcardiognphy study J Ms Soc — 2Cr! 1:2:122—121 .‘. 7 Ediocardiog,. One - a e was treated for possible cyst:lis seth PG Ciprofioxac. Thr dayse ;e .011W.. Higher Purpose. Greater Good Introduction Pertinent Images Differential Diagnosis

- Bactersi metin6s stttmpics. Cryptococcus galU is a fungal pathogen that is endemic in tropics and • Brain cancer (pt*nary or metastaiic) and United States Pacific It has caused outbreaks in British ColumbIa. Canada, r • Brain abscess biochentaNy Crypfococcus Northwest C. gatni is gonelicaly and distinct from • Crym intecbons noo&vnwm, and both account for most caseS ci cryptococcal In • Cys&ewosis often humans, aittough C. neo.tnnans mote colmilon. Both haigi manifest as • Focal eocephawis although is more coamlon in meningoence4,haWs andl pnmrwtt, C. gait • MyccIc aneslysm in hosts snwmaaonpolenf liosfs WIuIO COeOftWThenS ,mJThJnOCOntOrOniISOd • Septic cerebral embolt causing infarction • Septic durol sinus thrombosis Case Presentation

Patient is a 26 year-old male with PMH of Anxiety, insomnia, depression and yOU Discussion (used methamphetamine 3 weeks prior, history of needle sharing). He presented with worsening weakness in bitateral lower extremities over last 2 weeks. He was certain frees soil debris. In also having difficulty in urination and clenching buttocks. Denied levers. chills, • C. gatlu kifection is associated wiih exposure to and trauma or falls. Neurosurgery evaluated him and started Decadron. Vanromycin and particular, two species of Australian eucalypta (Eucalyptus calmaldulensis and hi left Ceftoasone which was switched to Vancomycin, Cefepime and Ftagyl. NB: Lobulsted, rim-enhancing lesion Euca!ypfus temficomis) anterior temporal lobe! inferior frontal lobe. • Hit? infection, organ transplantation, various maignancies, and receipt of measuring the Phnical Exeminafton: associaled cenbal restricted diffusion, glucocodicoids increase risk lorD. gait? disease known factor Neurdogic examination revealed bilateral lower extremity strength 4/5. 2.1 x 2.1 t 2.0 cm, likely cerebral abscess. • Idiopathic 004+ lymphopenia in the absence of Hit? inlec:ion is a risk Physical examination was oibers-,,se benign. C: Mild leptomenngeal enhancement along left (or cryptococcosis due loG, neofonnans and C. yank wifection. cerebral convexity, likely meningitis. Generalized • Hcst factors may ao inaease the risk for C, gaftdth’ecbon. A pmpod;on of Worku n: loss 01 sul CSF suppression in bilateral patients with this infection in Ncdh Aiierica had a history of dwonic king disease • Mill of Cervical flhoradcllimter spIne showed 3 separate intraspinal masses. cembfal and cerebellar solo and dsterns on associated v.ith smoking. infection One on el of m:dline at T5-6, second behind T8 19.5 x 9 x 9 man) and a third to F..AIR sequence without leptomoningeal • Crypiococcomas we larger and more colmisoti with C. gates remain poody infection the nght of midline at 79-10. (Figure 2. enhancement. Mild dilation lateral and third understood, there are increasing data that the immune response to profile of • MRI brain and CT head obtaIned. (See F:gure 1 A.B and C) ‘ventricles with mild hydmcephahn. among immunocompetent hosts plays a role. In one study, the cylokine healthy individuals was after in LP: peripheral blood mononuclear cells of eva’jated isolates isolates irfljced ‘3 CSF WBCs 91(80% lyniocyles), CSF protein 242 (high), glucose 34 (low, blood vitro stimulation with heat-k4ed Cr3pfoc000us of C. gaaii (11)-I-best, glucose 155). Bacterial .lungal and mycabacierial cultures no growth. higher concentrations ofitto p:cin9ammatcr cytolunes, intodeukks and the T helper 1722 c;tc’k.-ses. IL-I? and -3 CSF Cryplococcus antigen porive 1 80 tumor necrosis factor-alpha, and 114 negative, Toxoplasma PCR negative lL’22. compared with C. noolonnans. Toll-like receptor TLR “4 and fR-S. but not -3 CSF HSV 1+2 Figure 2: CSF Flow cytometry: No evidence of non-Hodgkin lymphoma or high-grade TLR-2. also contributed to the (wars cytokine response to C, yalta. Thera is ccrd edema from T54 down colony-stimulating myeloid neoplasm. • Store recently, it was reported that antigranulocyte-macrophage through Ti 1. There are 3 separate detected in plasma derived CSF Cytology negative for malignancy bus rare ciyploceccus bke structures factor (GM-CSF) autoantibodies were from intraspinal masses. The first is to the not specimen. CSF sent to University of Washington medical center immunocompetent pat:enis wth C. gaffal infection but in the plasma of patients present in left ot midline at T56 The second is negative for ciyptococcus infected with C. neofommns behind TB and is anterior to the left however he • Urine histoplasrnosis antigen negative Ourpafient did not have any obvious cause of immunow,ression. measuring about 9.5 x 9 x g mm. The may have exposure to eucalyptus or soit debris w/th the weed • Blastomyonsis serology negative wax a smoker and jrdisJo the right of rnidtine atT9-IOH • Cryptococcaltfters blood 1:160 or amphefamine he used. • HIt? negative, CD $ count 803. • Heb B (vaccination indeterminate) and Hess C (positive). • Blood and urine cultures remained negative. eiology of C,yptococcus gores? • Repeai Mill brain and thoracic spne showed no worsening of lesions References

Course of Illness: • ScrrelltC. Cryptococcustwoiom.ansvanetygattui. t.tedMi:ci 2DJ’;39155, • Started AmbisoneiFlucylosine induciton after passive CSF Crvptococcal arthgen. hi. • Chatiurvsdr V ChatuNedi 8, Cryplococcus gahi. a resssgeci lungal pathogen. • Latolnedomies 77. TB. TO & debulking of Ta infradural extramedullary spnai cord Trends ldicrob:oi 201I: 19.564. les:on. Aerobic/anaerobic culture no growth. lungal cutture grew ctyptacacws. - Nfl J. Lockhart S. Cheer T Cryptococous gaits where & we go from here? • Painoogy or Brain biopsy (intradural tes,cn showed Necrolnfiammatoiy debris Med Mycol 2012:50:113. and Yeast-like foims, consistent with cryplococcal species Gath F, Eeckels R. M atypical stran of Cryptococcus twotcwmans (San Felice) VulemIn 1894 I. Description of the disease and ot the sfri. Mn Son Belges Met Treatment: et Trap Parasitoi Mycol 1970. 50.689. Pat.eni started ksduction thety vit” mnphoiericr:t and fucytosine for B weeks Iot;owed by woe year of wnsokdatien therapy wills otal Flucona2ole daly. It wJi ho followed by maintenance therapy

Higher Purpose. Greater Good — -

Reconstructive techniques: A comparison of patient perceived outcomes .7 Ernst A, King ft Armbrecht E, Maher I.

Louis Louis, MO USA SAINT LOU IS Si. university, st U NV ER SIT Y. 01 ARMI NT or lii K MATO.OC V 1 Background Results Conclusions N=125 surveys distributed, 52 lime heals • $12 billion spent annually on ‘i Lowest mean POSAS scores scar related expenditures1 completed (42%) Mean POSAS kors by Court rye seen >160 days • Advent of scar assessment tools2 • Participant information: inn C, ttffien. fiputnini md ac-au 0;ea,’ No association between closure Vancouver Scar Scale • Repairs • type and mean POSAS scores No incorporation of patient • Linear: 27 • Only patients (9.6%) reported a perspective 5 ‘Flap: 16 score or 10 on any* POSAS • Patient Observer Scar of 9 • Graft/second intent: 9 item Assessment Scale (POSAS) i •_1111— — — Age I irs - SI • Within the 117-142 post-operative • Greater reliability and less to 93 years old day window variability than VSS3 • Range: 39 • Utilized in numerous scar • Mean: 70.1 years old studies46 Mean PC6A5 Scouts by O&n tp evaluation Cdt. utlWIres,mndOuaat Ofl, References to 1 Sen CX Gordillo GM. RayS, Kirsner R. Lambed L. Hunt

Methods - TX, et a[ Human skin wounds: a major and snowtalling • 9.6% (n5) patients reported a threat to public health and the economy Wound repair and score of 9 or 10 on any POSAS regeneration offloal pub!iat:on of the Wound Healing • RB-approved survey. ! Society Iandj the European Tissue Repair Society item iii ill ill ill iii 2009;17(6) 763-71. • Patient indentification L...erI 4_ ,,nfl’, din 2 Nedelec 8. ShankowskyA. Tredgelt EE Rating the • Highest POSAS score observed ‘L’keTh ‘FWfrtW •cfl.frlf • Inclusion criteria: resolving hypertrophic scar comparison of the Vancouver for Q5 (thickness) Scar Scale and scar volume. .1 Burn Care • Facial MMS with single stage • Mean: 3.4 Rehabil. 2000:21 205—12. repair Total POSAS Score was lower for patients sunned 3. Draaers U. Tempelman FR, Botman VA, Tuinebreijer • No significant difference iSO days post procedure WE. Middelkoop E. Kreis RW, et al. The patient and 18 years old observer scar assessment scale: a reliable and feasible between closure type (p=0.19) flu ma tool for scar evatuation. Plastic and reconstructive surgery. • 12 weeks removed from I i H 2004.113(7)1960-5; discussion 6-7 • No statistically significant I procedure date I 4 Chae JK, Kim JH. Kim EJ, Park K. Values of a Patient difference in mean POSAS CI and Observer Scar Assessment Scale to Evaluate the criteria I I I • Exclusion I .1 I Facial Skin Grail Scar Annals of dermatology between women and 1. I I • Multistage repair scores 2016,26(5) 615-23 men (17.4 vs 13.2, respectively) 5 Kappel 5, Kleinerman P. King TH. Sivamani P. Tayor 5, • < 12 weeks removed from -. I’. Nguyen U, et at. Does v.vund eversion improve cosmetc procedure date I ...‘-..L — outcome2 Results of a randomized. split-scar, comparative I _i that. Journal of the Amencan Academy of Dermatology. • Cross-sectional survey 2015 72(4) 666-73 • Data analysis 6 Raklyar E. Zloty DM. Use of a pat:ent and observer scar assessment scale to evaluate the V-V advancement flap for reconstruction 01 medial cheek detecis Dermatotogic surgery official publ:cat:on lorAmencan Society for Dermatologic Surgery fet alj. 201238(12) 1966-74 ______

Background Methods Results

• tiy toddler son ‘sliD is full of energy and my frustration wilh opinions • Focus groups. 19 groups of individuals composed of community how 10 dssdpline him was my inspiration membets. Cardinal Glennon Chitdren’s Hospital personnel and parents ot children edIt, traumatic backgrounds • Rates ot child naltrealmeni and noglect in Missoun have steadily increased since 2012 lou rule of 4 1 per ‘.000 chidren in 2015’ • Developed Trueing rnsanual based on focus group quaLtattye data. components from successlul sexual woleesee prevention program and • Data entry from medical student traning in process (actors Children From families in St. L.ouis City have the greatest nsk (or systemal:c review of bystander uilervenlion programs • Areas of interest maltreatment the lowest median thcome. highest povefl. highest • Typen ot interventions used befcre training .Traninq consists ot 7 modules to be completed over a 2 hour session SNAPitood stamp ebgibeity and highest rate at unemploynsent - • Most common perceived barriers • Pre & Post evaluations • Compare/contrast comfon ot intervening with “Bystander approaches have been successful in changing bystander witnessed threatening/yelling vs. physical harm abuse.iS • Role Play Scenarios altitudes and behaviors to prevent sexual violence and but Few • Did training change panictpants attitudes about their lidiatives have applied bystander principles to the prevention of chld • Call to ActionEstablish a persona plan role in the community abuse and neglect • Qualitative data regad.rg beneft of training Developed Brand Name that indudes acronym tar mays to respond • Focus groups ioinid that being tmcormaan about how to intervene lack of Saul Louis University Graduate students and community members personal responsibility for thld abuse and tes, ot negative underwent raining separately. Data cotected ansi used lo Fine tune Consequences inh:bil engagement and ir.tervenhno Discussion/Next steps training. “3 years ot Research developing Bystander Intervention model pnor to health care provider who experiences and witness slresstul I personally trained 4 Saint Louis University 3 year tAedical Students Ma parent and my joining leain child interactions it was tmponant tor me to have methods to provide using Supporl Over Silence for KIDS training material parent support. there will always be perceived burners to intervening and every interaction will not end as planned. However, ‘we are aiming to promote and Acknowledgments: support social norms that create a sense of I got your back: ycu have suppon.’ Partnering Onganizations among community members and hospital personal when they engage wish Continuum of Child Maltreatment parents and children ininstances of aggressive/neglectful parenting behavior”.’ Developed using focus group data Recognizing these interactions does not make the person a “bad parent’ but is rather reflects a bad moment in time, can help individuals intervene in non- SA,WTtosisewietmar fl•ro: so e judgmental manner, it is our responsibility to keep children safe as they cannot r’’Gleri’as connections 0 always tpeak for themselves. The qualitative data gathered tram trainings will be used to guide adaptations for future training. The goal is to develop a policy & culture at Cardinal Olennon children’s Hospital pertaining to child UPBR*ND maltzeatment and have all personnel trained, by Suppon over silence for KIDS, flhl.be,.Iin to intervene inana ppropriate and effective manner.

Objectives References

• Support Over Silence for KIDS 1. Weaver Ni., et al. Bystander Training Manual oraft. 51.0 (ROn 28093. • Reduce puniopants banters for intervening 2. tsner 0, cumm:ngs N implicat ons tar Seauat Assault Prerentcn: college

• Increase participants’ ownership and positive hitention — tudentsa 5 Prosocial Bystanders. JAm Coil Heel. 2Oit Ss(7t:t556S7 to intervene l ll1(ltllli 3. coker Al, Fisher 65, Bush HM. et al. tvaluation ct the Green Dot Bystander • increase participants confidence tn assessing and Intervention to Reduce interpersonal Violence Among college Students Across reactbsg to a variety of satuattons Three Campuses. Violence A ;ains F Women. 2o14;21ts2):soSI.1527 • Increase how often bystanders provide support to 3. Moynihan NM, uanyard VI, Cares AC. Potter SI, Wsams IM. Stapleton JR caregivers and me ctsidren Encouragieg let pontes in Setual and Relationship Violence Prevention: What Personal Program rttects Remain 1 yearLater? J Interperv Violence. IolS:sllt:lio1a2. Provide medical students with insight ot irequency and S. Crimaru M. Encouraging bystanders to helps stopping siolence against foims ci chdd maltreatment. banters to inlervening and children. itt I Ncnprr/,r vcfsnr Sea Mark. 2013;1a43):7’l? methods to oyercome those banters — 6. Mnaoun Oepanment of social Servsces Children’s oreiaion. Chdd Abuse and Get future providers thinking of how we could best Neglect Fiscal year 2056 Annual Rerun 2056). tttR lit’ - intervene in a suppodtng manner that doesn’t Fracture 1 SSM Cardinal Giennon Chuldret . ‘.‘. cal Center. Community Health: Needs the ongoing relationships with (amities Assessment 2012. 15551 Heaithcai ______

Wild Wild West Nile: Fever and Encephalitis West of the Mississippi in an Elderly Patient Debapria Das, MD; Sandeep Thmmala, MD; Andrea Gomez-Ramirez, MD; Rachna Rawal, MD; Keniesha 0. Thompson, MD oepat,meid St Ielemal Medcne Semi Louts University Sctiod & Metcne Introduction Figures Discussion • Less than 1% of West Nile infections result in neurotogic Recognize West Nile Disease as a cause of acute febrile 1,4 4- encephalopathy in the geriatric population. sequelae, with mortality increasing with age independent of West Nile virus was not identified in the United States until medical comorbidities. isa 20-laid neurotogical involvement 1999; now with increasing documented cases over the last • There increase in risk for decade in patients older than 60 years. 80% of infections are asymptomatic. -- • Increased susceptibility in the elderly is due to increased permeability of the blood-brain barrier due to effects of aging. 20% develop a influenza-like illness lasting three to six days. I (NI • Mortality of neuroinvasive disease may be as high as 25%. Case -fl • Confirmation of diagnosis by molecular or serologic testing can take days. • 86-year-old woman presented for altered mental stalus in ‘Is extremity tremors and changes in ‘.. • Bilateral coarse upper September ii iiIi iN subcortical. and meningeal hyperintensities on • The patient was independent with all activities of daily living. I liispi Cal Dan periventricular. MRI may suggest the presence of neuroinvasive West Nile prior • A week prior developed a cough and slow mentation. I’ ‘ 1ff 103 •,I I ièmpanturc to serological confirmation. Physical Exam and Initial Resutts: Figure 2. MRI B,n dEsplays 88% on RA Figure I. Tred of fever. leukccytos;s, and ineit stanis deheg • There are currently no therapeutic treatments availabte for BP 155/58IPulse 95lTemp 1035FlResp 2BISpO2 pedvenlncular. deep and sebcortcal white right hospEtizatEon. Demonstrates con’jceed febrile spikes and steady treatment or prevention of West Nile Disease o A.AOxO, inability to follow commands, sided gaze m41& FLAIR hyperEntensis which ate were unremarkable. ,srnase rn rne.qaton despite dectease n leuky:osis after niliation o • Supportive care and rehabilitation post-discharge result in o Initial labs and CT Head advanced for e wh.ch may itd:cale be pneumoniae an S functionat and cognitive recovery in up to 88% of patients. o Urine Culture growing Ktebsiella wese.9:e of West Nie Vims. • Retained neurotogical deficits were more likely in patients

Course of Medical Disease greater than 75 years old. Conclusions Dayl DayS Oay7 Day 14 Day 17-21 Day 25 Day 2—l2 oay3 West Nile disease can present in the elderly as lever with acute Acydovir and Watt Nile • car West NLIe • Paneet • Started on • Bilateral upper Enteral vancomydn extremity tremors nutrition Badnm positive in successfully positive in monitored for encephalopathy. especially in months with mosquito activity. started for serum tated;1fter CSF cettflaxnne reduced with started • Patients may be Initially misdiagnosed due to other and fiagyl Ativan • Blood possible meningitis showtng rio supportive and Then confounding factors. for UTI and - MRt and EEG do cultures aapwali&t bactn care to not indicate acute negative dhited • In patients with unexplained encephalopathy, it is important to pneumofla intraaa:aI :• . mnng consider West Nile virus in your differential. poceasor • At antibotics and antivtrais I.,, - faohly seizures - I 4 -. Failure to Tolerate P0: Incubating Tricuspid Endocarditis During Treatment with Oral Antibiotics Debapria Das, MD, Sandeep Tummala, MD, Rachna Rawal, MD Department of Intemal Medione Saint Louis University school or Medicine

Background Images/ Tables Discussion with drug abuse and RighI sided infective endocarditis makes up to 10% of total - Embolic events are more frequent in patients IV endocarditis cases and is associated with an overall mortality right-sided infective endocardit;s. • Vegetat:ons which are >10mm or are noted to have severe mob:Iity up to 15%. are associated with increased embolic risk especaliy in S. aureus infective endocarditis (WIE) is associated •Tricuspid valve and S. bows infections with IV use (40%) drug - Vegetations >15mm are a predctor for 1-year mortality • S. aureus is the causative agent in 70% of cases - Tricuspid vegetations can allen be larger and are more mobile • Most WIE cases are treated medically with IV antibiotics with compared to left sided vegetalions due to low pressures in the right 4% requiring surgery head ‘The POET trial demonstrated that after clinical stabilization • Was there potential harm from using oral antibiotics from of IV antibiotics in left sided I applying the results of the POET trial to our patient? with at least 10 days endocarditis, continuing medical therapy with oral antibiotics White the POET trial showed that oral antibiotics were the trial focused was a non-inferior treatment option. noninferior when comparing embohc outcomes, on patients with left sided infective endocarditis of which only Case 45% had vegetations >gmm a Tricuspid vegetations >10mm have been shown to be safely chief complaint: 28- year old female presents with severe right Figure 1. treated with IV antibiotics if no other surgical indication is upper back and right lower chest pain with dyspnea beginning A) CTA: Mycolic pulmonary artery pseudoaneurysm wiih pleural effusion. present, however there is a lack in data displaying outcomes of morning of presentation B) CIA Mycotic pseudoaneurysm with thrombosis, pulmonary infraction with pleural effusion. early surgery in right sided endocarditis Medical history: lVmethamphetamine use Development of an emboi:c event in infective endocard;bs after Additional History: Was discharged with 3 weeks of Didoxacillin 13 14 dafl of aooronr ‘e antibipticireatment is uncommon days prior for continued treatment of MSSA tncuspid endocarditis Patient endorses medical compliance. Conclusions after 3 weeks of IV antib:otics Figure 2. Physical Exam: HE. HigF,iy noie A)Adndssion - There is a lack of data on use of oral antib:otics and early surgery o BP IlonolPulse ll3ITemp 98 7FIResp 96% on RA 24l5p02 tricuspid waive vegelaiion on outcomes in W1E o Significant for diffuse tenderness to palpation along right chest measuring 17mm x 12mm will, - There is inaeased risk of embotic events due to large vegetaton wall and back moderate riaispid regwgiiaI:on size in both left and nght sided endocarditis Labs: Hc0231. WOO 132, Hgb 109 8) Final TEE. vegetation measunng Microbiology: No growth in blood cuiture& 16mm x 12mm on the posterior - Our patient does not fit [he cntena tested in the POET trial, clinical course: leaflet of the tncuspid valve with • We recommend using caution when considering switching to oral o Started on Nafciiiin and completed 4 week course moderate tricuspid regurgitation. antibiotics in patients with large vegetations o Discharged with planned follow up for moderate tricuspid regurgitation and monitoring of pulmonary artery pseudoaneurysm. ______

Background I Results I Conclusions • 5-10% of skin cancers occur in the periocular • 210 patients included in the analysis • Similar defect size, location, and repair types region • Average defect size was 2.2cm2 as those reported in the oculopla5tics • Mohs micrographic surgery (MMS) is considered • Repair types included linear repair (41%), advancement literature the treatment of choice for periocular tumors flaps (27%), transposition flaps (18%), rotation flaps (7%), • Similar to previous studies, the most common • Repair of periocular defects poses unique second intent (3%) and lull-thickness skin grafts (3%) locations for periocular tumors in our study challenges • 30 complications observed in total (14.3%) were the lower eyelid (42%) and medial • Complication rates of periocular defects repaired • Most common locations post-reconstruction canthus (33%) by oculoplastic surgeons ranges from 16-42% complications were the medial canthus (17/30, or 56.7%) • The overall complication rate of 14.3% is lower • Data on the safety of periocular repairs by Mohs and lower eyelid (11/30 or 36.7%), accounting for 93% of than complication rates of 16-42% reported in surgeons is limited all complication locations the oculoplastics literature Disclosure . Eight patients (28%) with complications declined • Majority of complications were managed treatment or were managed conservatively. The most conservatively with scar massage or • The authors have no relevant financial common post-operative intervention was intralesional intralesional steroids disclosures triamcinolone, utilized in 43.3% of complication cases. Scar revision was performed in a total of 5 cases (2.4% of Limitations Objectives • Retrospective all cases). study • Analyze the frequency and types of post- • Lack lost to follow up Post-Operative Complications and Interventions of data for patients reconstruction complications for periocular • Selection bias—? larger or more involved cases Location Repair WI’. Conwlkitton firn I repairs performed by Mohs surgeons J referred to oculoplastic surgeons U A No KC taunaJ canthaa. Aaoc-catneo flap Lwpp.p,t Decked risk with No Loea,eId Retain, flap Fcoep.ea’ Decked • Identify factors associated 91’ M San • Limited to repairs performed by a small 57 II Nt CC tanrtd Mea,a,tnflap Srw,Øp.t Nete complications epaulet 0 IA No ‘CC tapr Ld Canaan Lnnoeen. tp.eIna iLl S tear number of Mohs surgeons working at • Enumerate interventions for complications 47 F lea C loper lid Mea.nn,n* flap I erhera Netp a p leo pa Leeppnld Reuttet flap “rneuei,c iLSLIAI,,pnnaa.. academic institutions encountered 70 1 No ‘CC loSte .4 Cann Henrnk a 5 ‘patio., 62 r No ‘CC Mved.a.deat t.a,’oriesr’Pop Hnrn0w.a. 55 SI P Na ‘CC M,’ttaIca,mPlat i-ar,pe,.tet Nyp.fl,nØw a Ri References Methods 91’ II No ‘CC Wesaa tRfl La,ees’r — PPrn5IlA5n as 1 Cook BE, Jr sanley 05. Epicernio1cic chancr,ri stirs and clinical course of pal:erts N LI No ‘CC I/r*dtaee.a wtuow-r.w — N,pnvpsøw a Ri • with nalgr.ant eyelid tumors in an incid ence cohort in emoted Coanty, • IRS-approved retrospective two-center study N F C.. ‘CC P,’eSStsleun II0 ItpppnrnØ.c I pm, Minnesota. Opfmlfislnology 19S9;10S4l 146-750. LP IA Yet •CC •‘ejoceea ln.ewa.,tee Nnwnooa a PS 2. OHalloran L Smith H, VinciLdlo C Persocular Mobs m-crographc sumEery in Western • Periocular reconstructions by Mohs surgeons 10 F Nil Upon hI Tetewe.,Ret Rap ta,wnlrsaaet a CDL Australia 2009-2012: A sirgec entre retrospective review and proposal for practice St IA No ‘CC cone, a Relate, flap tadaine, b.r.chrnamks Asslmins I Vermstol 2017;5612l: 106-I ID. between 07/2013—06/2016 were identified in F No ‘CC tee.. SI aea,a.te.n flap h*ro’p, ktXI 3-sin CW, Barua A, Cook A. Recurrence rates of periocular basal cell carcinoma following 10 F Ni, PC’ LIrdi caIau Can’Øet t.datie. k,abcteos Ms hu microgra ph:c surgery a retrospect.ve stsdy lr.rJ De’mofot • Patient demographics and tumor/surgical details 7t IA ntIs ‘CC Medal rflt,n Ieam’Ra’ — MeSal eonII,4 ..et 65 201655l5l20$4-1047. 10 p., ICC .Idal canow, d.eene,* Pap Ibdal ra...4 — Ne.,e 4. Michelont 5, Mats, P Rcberts 1, travelare C, Billingtley C, Wilkrrson M. Peciorbital were recorded 57 P No ‘CC Medal rand-au leanecut.ee — Medal ra,thal pet itS Mob, r.constpuctior: claranerloation of tumor histology, anatorn:c location, and • Follow-up visit notes were reviewed for post 55 N No ICC Medal wte, fàeaanewti Sap Medal etmd,al — ka ‘prose factor, influencing postcperac-ve complcalions Dirmotol Surg 2012;4C-U-Di 1032- SONnet Pr: Mr*Ma.Wu,. tenpoene Rap Medal raemue.eb PS 1093. operative complications and interventions a a Ian ‘Cc Medal tMe,nn Tet,wnss’w Sandal ra,d,aa pet bee 5. Kumar B, loden 0, Vmnciullo C, Elton IA mevew o124 caues of Mobs surge-my and Si P No ICC Medal caatkn fpwneu,tpe — Metal ta,ithaa — ‘LI & 0 Fraser ophthalmic p lastic reconstrocujon. Auto N 2’ slh,lmoI 1997,25(41:269-295. • Complication rates in relation to patient St P Nt Pa Medalcacalpo (opeN:. MesMw-,hj None 6. [embov,tch I, Huilgol SC, Hsuan JO, Selva 0. lncidc ire of N oil site corn pications in Es ER No IcC Medaauaetha, InaNe, Rap laed.at c,am,d.i — ill perioctlar full thickness nkin grafts. gel Opi, snot 200589l21219-222, eetodrenrg Pm, demographics and defect characteristics were 57 F No fl peer I I CaniNe, 7 Saito A, Slim N. Furuka Wa H, eta!. Reconstru ot ripen orbital defects following 64 IA Yes ICC Leper mad Adnaw cccii. lao fl,pwthocrg N-sr malignant tumour etcis ion: a report of SO ca - ‘fout Recontfr scoUter Somg. analyzed Si IA Fad ncr Medinaa,,hau Daenpeuaiap flap Fam,cutn,Ig lOt 2:65151:665-670. — —

,i’r ,‘r’— ‘r’--”: - “‘‘1-, ,?zxrrZr4i’t-,-,.-—. —A. :, -rr-rr”mvr’ .4. ‘-‘rv” ‘;flrr rrr’r ‘We’m:-,,,tl Assessment of Sunscreen Knowledge Among Lifeguards SAINT LOUIS U HIVE A SIt? Courtney C. Crider, M.D., Kavita Darji, M.D., Sre Gorukanti, 8.5., Jacob Dudzinski, B.S., Eric Armbrecht, Ph.D., Sofia Chaudhry, M.D., Mallory S. Abate, M.D. Saint Louis University (SLU) Department of Dermatology, Saint Louis, Missouri

I:FTR:t.It.]IIinI Demograohics Ultraviolet radiation (UVR) is a major risk factor in (he Overall sunscreen knowledge scores for new and returning • 118 lifeguards completed the survey (97 new, 21 retuming) development of skin cancer. lifeguards were low based on survey responses, • Mean age 17 (range 67% female, Fitzpatrick types I-V (47% type Ill) Sunscreens are designed to block and/or absorb UVR. however 1545), • Thus, many lifeguards could be at risk for excessive UVR personal history of skin cancer, 24% family history of skin cancer sunscreens are often used incorrectly by the public, possibly • 2% with exposure and ultimately skin cancer due to lack of knowledge regarding sunscreen lerminology, Survey Response Summary Returning lifeguards who reported applying sunscreen more proper use, and/or overall benefits. • Average Total Sunscreen Knowledge Score 3.5(10 (range 0/10-8/10) often before and during shifts had higher average total scores. Lifeguards are at an increased risk for excessive UVR exposure. • 93% of responders knew SPF was important when choosing a sunscreen, • Knowledge likely influences behavior bul behavior may thus it is crucial they have a high level of sunscreen knowledge. but only 31% knew the minimum recommended SPF value (30) also reinforce knowledge, Previous studies have examined patterns of sunscreen use, sun • 27% thought the minimum SPF was less than 3D (or didn’t know) Improved educational programs focusing on sunscreen and sun protection habits, and sunbum frequency of lifeguards, but • 10% knew how SPF # related to time spent in the sun without burning protection at lifeguard trainIng classes could help bridge the information regarding sunscreen knowledge is lacking. • 57% knew to apply sunscreen 15-30 mins before going outside gap in basic sunscreen knowledge among lifeguards. • 31% thought one could apply sunscreen <15 mins before (or didn’t know) • 42% of survey responders knew to reapply sunscreen every 2 hrs Objectives • 30% thought sunscreen could be reapplied ‘every 2 hrs (or didn’t know) • 48% knew 1 ounce of sunscreen is needed to cover an average size adult Our goal was to assess basic sunscreen knowledge among new • Sample size (118 surveys collected) • 35% thought only 1 teaspoon of sunscreen was needed (or didn’t know) and returning lifeguards at local lifeguard training classes. - Lifeguard classes located in one metropolitan area (St. Louis) 50% knew what the term broad spectrum’ means on sunscreen labels By determining gaps in sunscreen knowledge among lifeguards, Lack of validation of survey prior to study • 61% knew what the term “water-resistanF means on sunscreen labels we can better design sun protection education programs for lifeguard training classes in the future. Differences by Demographics

- Older age and more years of lifeguard experience were correlated with higher average total knowledge scores (p=O.00l and p=D,037 respectively) 1. Wang 50. Duaza SW. ‘Assessment of sunscreen knowledge: a pilot suivey. UnlisI, Journal of Donnalology. 2009:161 (Suppl. 3): 28—32. Methods • New lifeguards = 3.4/10; Return lifeguards = 4.5110 2. Gies P Glanz K, O’Riordan 0, ctlioi T NehI c. ‘Measured occupational - Gender, Fitzpatrick type, & skin cancer history were not statistically significant. New and returning lifeguards attending local lifeguard saiar uVR exposures of lifeguards in pool settings: American Journal of • Returning lileguards who reported applying sunscreen more often before and 2009: 52: 645-653. certification classes were asked to complete a 10 question Indusiriol Med,crna during shifts had higher average total knowledge scores (see graph below). 3. Hail DM, Mccarty F Eilioi T Gianz K. tifeguard’s sun proicction habits basic knowledge survey tesLing sunscreen and sunbums.’ Archives of Oermalniogy 2009; 145t2)’ 139.144. Demographic information. personal/family history of skin cancer. 4. Hiemstra M. Glanz K. NeN E. ‘changes in sunburn and tanmng auitudes and years of lifeguard experience were also collected. among irteguards during a sununer season, Journal cf the American • Correct answers were summed to create a total sunscreen Academy cfDemiatology 2012; 66(3): 430-437 Va’id.iy of SeS knowledge score (i.e.. /t out of 10). & o’Riordan 0, Glanz K, Gies P. Elt ot T ‘A Riot Study of the reported ultraviolet Radiation cxposure and sun Protect:on Practices - American Academy of Dermatology sunscreen guidelines The Among Lifeguards. Parents and children: Pholochemist,y and were used in creating survey questions, Pholobiology 2006:84: 774—778. • T-tests and analysis of variance were used for data analysis, 6. American Academy of Dermatology. Prevenl Sk:n cancer. ‘How to select

- This study was approved by the SLU Institutional Review Board. a Sunscreen’. ‘How to Apply Sunscreen.’ 2018. ______

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Stone Cold Crazy: A Case Report of Nephrolithiasis and Empagliflozin Induced Diabetic Ketoacidosis Jordan Hend,jckson, MD, Sandeep Tummala, MD, Kenlesha Thompson, MD t Deoalrnent of inlarnai Me±crM Sam Louis urigersiy Schoci cf kel ne

Background Figure I. Evolution of OKA Labs Over Time Discussion 150 S’J . ETgIucose leads to •SGLT2 Inhtbilors are novel anti-glycemics includ’ng canagliflozin states induced by SGLT2 tnhibitors keto enic (2013), empagliflozin (2014). dapagliflozin (2014). and erlugliflozin increased lipolysis, gluconeogenesis, and a mild state

Sw ‘. kelogenic or (2018) that reduce blood glucose levels by selectivey blocking Periods of reduced oral intake. low-carbohydrate 11 these glucose reuptake the proximal tubules in the kidney diets, and infectious/inflammatory states can exacerbate state of euglycemic ketoacidosis. • In 2015. the FDA released a warning regarding the association -i effects and lead to a < elevated between SGLT-2 inhibilors and euglycemic ketoaodosis (euDI) I EuDI’ is diagnosed with serum glucose 250 mg/dL, 120 anton gap, elevated serum ketones. serum bicarbonate <14 E Case I , mmot/L, and arterial pH <7.3. -Treatment should locus on closing the anion gap using an insulin • 53M with history of insulin-dependent T2DM presents to an drip, aggressive fluid replacement with dextrose replacement 10 outside hospital with abdominal pain, emesis and poor oral intake i keep serum glucose between 150-200 mgldL. potassium non-obstructive nephrolithiasis supplementation, and as needed bcarbonaie suppIementatcn. for 3 days and diagnosed with z ia •Metfcrmin, empagliflozin. and sliding scale insulin started On Figure 2. DepictIng Development of EuDRA admission. • Day 3 or hospitalization he becomes somnolent and odented only to sell He is transferred to our institut:on for further evaluation. • On presentation he arouses to phys:sal stimulus is oriented to sell and reporting signifcant abdominal pain. ib(, 507 i5.,N • Vitals signs were significant only for Blood Pressure of 1951108. I - 5._I 11n1 5.’] 504 ih5 a’. aiiiiii —.i,A i:,, • Initial labs revealed Glucose 135, AG 20, 002 13, Arterial pH 7.31 + :‘:-: Medical Course After Arrival Ii — ‘III — Day 4 Day 5 Day 6 Day 7 Day 8 Conclusions • Patient • Sliding Scale • Medication Alert and • Discharged to Transferred to Insulin Started review revealed I Oriented x3 SNF on Insulin • Hospaalists should be aware of the nsks associated with Glargine and our institution • Methanol association I • Insulin Gtargine oral intake and must Mettormin continutng SGLT-2 inhibitors with poor Ethylene gtycol. between SGLT-2 initiated consider discontinuing these medications during acute Salicylate tabs Inhibitors and • Empaglitlozin euDKA stopped hospitalization. E!zin negative a • Patients should be counseled on the risk of SGLT-2 Inhib;tor use Stopped • Begins following • Endocrinology commands lollav up and restrictive diets Somnolent & scheduled L Oriented xl ______

A Good Run of Bad Luck: A case of osteomyelitis of the pubic symphysis in a young athlete Sandeep Tummala, MO, Jordan Hendrickson, MD, Keniesha Thompson, MD Department of Internal Medicine. Saint Louis University School of Medione

Background______images Discussion in 3-5% related injuries. I. Osteomyclitis pubis isa rare Infection involving the pubic • Osteitis pubis occurs 0f athlete symphysis and Its joint - Osteomyelitis pubis is a progression of osteitis pubis. a It accounts for less than 1% of cases of osteomyelitis. The pathogenesis is attributed to micro trauma with repetitive that makes it susceptible to seeding. - The most common organism isolated is Staphylococcus aureus, movement during sports j followed by gram-negative bacilli, and polymicrobial infection in Osteomyelltis pubis presents with fever and pubic pain which recent pelvic surgery. radiates to the genitals and increases when the hip is mobilized, producing gait claudication. Case • Diagnosis is based on clinical presentation, supported by culture results and imaging. 20-year-old female wilh no significant pest medical history - MRI is the most reliable method of detection. presented with groin pain and fever(102F). - A large case series determined that diagnosis early in the course She is a college athlete who runs ten miles daily. of osteitis pubis allows early on conservative management Had recently gone zip-lining; wore a groin harness. treatment: resulting In return to play faster without progression to - No trauma, lesions, abrasions. osteomyelitis pubis. - 2 weeks of progressive bilateral inguinal pain worse with • Conservative therapy for osteitis pubis includes: rest, non ambulation. steroidal anti-inflammatory drugs, physical therapy and - Significant Labs: WBC 126(72% neutrophits), Lactic acid of 1.2, Figure 1: MRI: 42 nm rim Airated cLcliDn anterior pelvis abutting the pubic compression shorts. ESR of 59( N is 0-20 MMIHR) and CRP 6.UN is c0.SmgIdl syeeehyis - —— - Once progressed to osteomyelitis pubis, management changes to drainage, antibiotics and In rare causes even surgery. Course of Medical Illness

DAY Conclusions DAT I OAT S Fk.d snt unit Repeal ci emend 5- - Osteomyelitis pubis should be suspected in a patient with acute 0—s atiaw.e avowed Ieojaled oeiuu,aeaed pelati onset of pubic symphysis pain, fever and symptoms of systemic C— — MSSA mad abasess and TEE a Sand co involvement. s__ ‘0 sit ,ngab,e ass e.tel.w. Da$pmype, - The standard treatment is a prolonged course of intravenous and oral antibiolics and abscess drainage if possible. • Awareness and early recognition of osteitis pubis can prevent ._.. •t . . • disease progression and unnecessary invasive treatment. OAYZ — DM4 DM50 CrasdtdlR Patient thareed at Thepeth ataee detenn,ied sn6werkcesne &.dand elseaveenas slatted en no sWe1 ittarserotn ,eaftn with elsie Lsefienaiin ,thcaled toe up we, be, team to the Xray Erosive changes and and Figure 2: US. Anechoic fluid posterior FigureS: esleemeettu dade, Va,,coriicei uterus in the cul-de-sac loint ig,egularily-ueen in osteitis pubis ______

Religiosity in Relation to Violence and Crime: Risk or Protective Factor? Elias Ghossoub, MD, MSc’ Department of Psychiatry and Behavioral Neuroscienee, Forensic Psychiatry Division, Saint Louis Universityt Missouri SAINT LOUIS a.. .fl:.1 I S’

BACKGROUND RESULTS METhODS

Es cc smee Enisle Durkheim published his — Dais, publicly-available cc 055-sectional suneys of the National Siinev on seminal ssork on lie associai,on ofreligious Drug Use and health (NSDUIII from 2008 through 2014, N= 270227 adulis 90% affiliation and social Intreratton sviiht Dependent riahlcs suicide, rrliiziosiiy has been considered a 01% — Self-report of asiemptinu suietde and petpesrattnr a phi sical assault over pioscrits e factor against suicidal thoughts 751% lie past year ansi heltas tort 60% — SclCicpnn ofbeing anes ted 05cr tie past yea,

— ((eli dash’ s nci,eci ise effect againso ‘IP. — Religiosity Questions suicide is behcsed to stern from the impact 40% — Religious beliefs arc vet’s- important in life ii 05cr a portals’s belief stem eserc:ses so Jut and die Iromotian of communti’ — Relieious beliefs influence deentons Zr. connectedness It a important nut relissioim a beliefs are ahiared ss titi friends 10% — Rehgtous affilnison and panicipatton can be — Self-repon of number of religious sen-ices attended oser the past inc on protectis e aains attempted sin cide. pease? Re:igasus a Non-Ret lion Decissuns Fnenth Sen tees — Independent Variable can hiosseser be a risk facto. Imponance N nn-ieligaous Dnsawetd smith all nlatmnnsts and dad non aitendoeligaoos — Prior resessech suggests shut there a an ar. 79.6% II .3% 79.7% Sen ices Over the past year inserse relationship beisseen religiosity and is”. been Religious Agreed sulk any statement or attended at least one religious enme. as rel,gtostiy lisa generally 70s 63.3% 63.7% del inquency and senice over the past sear found to inhibit youth sor. ‘‘ 56.4% adult crime — Analyses

— 11t2 — for h isaciale ssnli Vonferroni adjustment for Diffcrezit causal mechanisms have been Adjusted F tesi analyses, proposed, including thai relimonity multiple testing promotes social confonsitty and fear of Multiple logistic regression models to detennine odds raiios of attempting b2j.I punishment I:: suicide physically assaulting another person and rciisng arrested over the — The association ofreligiosin- and ens, e has ii1i IIEr.i% 15151 year not been thoroughly rrsrai ched in the Past-Year Attnnptcd Suirt& Past- ‘lea, Physical Assault last - Year “nest published rek liiaatiae. and moo saw ica • lniponance • Dectsiorss a Fnenth • Iligh Senice Ahendance U Rc!snous CONCLUSIONS On ecological desimis Pate-jar • Itisponarce of religious beliefs in life and decmsson-nsaking air insenels Pant-lear Saleide Past-lear OBJECTIVES Combined Pait-jear Arrest correlated to violence Attempt Physical Assault joIe*ce — tligh atter.dance to relissious sen-ices is associated 5’ iiti decreased odds of — To understand tic impaci of religiosity on a4iO5iU.i. .eig.qsta;, iimØo’sci) t( 00%Lii getting arrested sclf-duected and mlie,-ditecied siolenee — Composite measure nf religiostiv are assa tated scish decreased odds of

— To undessiand fir association of religiosity 5. infrnei iso in so 5.u,frn.i aitcmped ss irii!e hut ale aaot associated ss-nh pcqseiraiang physical aasaiala ills crime tO 525-tOt tat it.78.aMi toT isis silts 594 iii 90t s1s — Composite measure ofreliriosit yts ooi associated ssiihi getting amested — To esplore lie association of cenain — — t’rospecusesiudie 5 are needed 0 gauge the pedbmiance of religiosity as a aspects of religiosity 55 nIt s totenre and L S,{rm,..noi Ito predictis e farinr offuturesi olence andor crime Crime 5. imnermnm,i Ito Lii HO L 0.52 it70-C%i t.77 itO-SWIm 079(0051 ) Oshistb-t riot ci Sadal Cimsie RE FE RE N C ES KNO% LEDGE GAP L___ria - 5. adios,.> I 5)) L___ tmnk..,mi ito - Ito Ito — Adanicr - Freilicti, 3D - & Kim C (2017) Religion and Crime A iiiYiv99-LW) - L , — Ones religiosiiy maintain a prolective effect i 5) it.twt sit 092 sO 02-i sit tin 5079-ho) L Si stematic Reviesv and A sse ssnaeisl of Nest Steps Suruiih.gr ufRehgiu,i: A aranast s iolence and crime ‘slien arcowsiing teflk,Mtui.dan bnkeai.aee (hianrrlj Roses: 00 0 I - for confoundtng factors’ 5.e i,eeim..mi mm, isa iso ..a, imnkmnai i to - (2016) — L asssenre - R E - Oquenda. .l A & Stanley. B Religion and — Ai c coinjxssite measures olie ligiositv more F 01300 704 tO) tail tS-IAt5 aotsmt lot i.iUtIml-m ta Suicide Risk A Ss sientussc Hes tess itrhnencij,Viouc,Jc Reteunfu 1 I), I - atronctyrorne lased to siolessee and cuine •_im.han,,i Osjr_eI.i lot i 45074 i - —. a flit 4s-n.L’i shun wiidnaensional nieasssres’ 5d554ai07 - —— —- - —a • Niahti B et al (20l7) Use association of1wsaonal impunsare ofrelimon and

iso to - so 6.*kmn’o) ton religtous sent re attendance ss nIt suicidal ideation by age croup tn the

— 53 ‘9-LISt fl to 46-i 49 rI National Sssney on Dmg Se and health Pstrhwrn Reu’unh. 255, 321- —

io-eoealin ,os ,r naiad isnsi I,.w tipe d5 S.d aia 4ti5..n pan.enu_i... i.almen’ ai,..e 5a-,ie’ — 3:7 jii as,a. i—S-re— S.ire a..o. 0 *..nd ma. saMis,iak.arr . sr_ia iat irare 59 — %SDL5II data was reirtes cii fni::n ibm lnta-untsei Lily Consortium for ad_ia - Political and Socssh R eseserts IC PS K I data rrpositon SE?!

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Underutilization of Esophageal Biopsies in Evaluation of Dysphagia May Contribute to Underdiagnosis of Eosinophilic Esophagitis

UJE Ahmad Al-Taee, MD12; Kahee Mohammed, MD, MPH2; Charlene Prather, MD, MPH1-2 ‘Division of Gastroenlerology and Hepatology, 2Department of inlernal Medicine. Saint Louis University School of Medicine. Saint Louis, MO Results Introduction H,,p ,taaaiti an, Pt, Wa’ Eosinophilic esophagitis (E0E) is an increasingly recognized JJ -t An increase in the number of annual hospitalizations for chronic immune-mediated condition that can present with EoE was noted over the study period (figure 1). esophageal dysphagia. -it-— Among hospitalized EoE patients, the majority of patients We hypothesized that the regional differences in EoE were in 18-44 age group (49.7%), male (60%), white prevalence are related in pad to the regional differences in ethnicity (80.3%), and were admitted to a teaching hospital obtaining esophageal biopsies in patients wht (67.6%) in the South (30.7%, figure 3). endoscopcally unexplained dysphagia. Among adult patients hospitalized with endoscopically

ryn 3 unexplained dysphagia, only 53% underwent esophageal Methods biopsies during EGD (figure 2).

‘We utilized the national inpatient sample database for the Conclusion years 2008-2013. using ICD-9 codes.

• We idenlified 4073 hospitalized adult patients with EoE as - Esophageal biopsies may be underutilized in evaluabon of well as 112534 hospitalized adult patients with dysphagia patients with endoscopically unexplained esophageal with no explanation on upper endoscopy (EGD). dysphagia. • Weighted multivahate logistic regression models were used • Regional differences in EoE prevalence could be explained to examine the regional differences in EoE hospitalizations in part by the regional variation in the rates of obtaining and in the rates of obtaining esophageal biopsies during esophageal biopsies during upper endoscopic evaluation of EGD for patients hospitalized with dysphagia. patients with dysphagia. rç,m 2 rçn 4 Not Every Non-Alcoholic Fatty Liver is Non-alcoholic Fatty Liver Disease SAINT LOUIS Ahmad Al-Taee, MD’; Nicholas 0. Davidson, MD, D5c2; Brent Neuschwander-Tetri, MD’ 1Division of Gasiroenterology and Hepatology, Deparlmeni of internal Medicine. Saint Louis University School of Medicine. SI Louis. MO. 2Washinglon Universily School of Medicine, St Louis, MO.

Introduction DIscussion Lab Test Result Reference Range Non-alcoholic fatty liver disease (NAFLD) is defined as, Familial hypobetalipoproteinemia (FHBL) is autosomali cac within normal limits codominant disorder that results from mutations of the Apo hepabc steatosis in the absence of 2ry causes of hepatic! BMP. iNR. AIM’, and PT Vihin normal limits steatosis. AlT 116 mgJdl 9.46 mg/dL B gene (figure 1) which plays an impodant role in Iipd NAFLO is the most common cause of chronic liver disease] AST 61 mg/dL 0.42 mg/dL metabolism (ftgure 2). and is strongly associated wilh metabolic syndrome. Total rhotaslerol 47 mg/di. 125-200 mg/dI Patients are usually asymptomatic although some may] Trigiyceride 73 mg/dL c 150 mg/dL develop hepatic steatosis (or more advanced chronic liver] 13 mg/dL 130 disease), intestinal fat malabsorption and resultant fat-] Cases LOL HOL 25 mg/dI 40-59 mg/dL soluble vitamin deficiencies. 34 year-old man was referred to our clinic for evaluation of Apo 5100 ievei <30 mg/dL 52-109 ne/rft • FBHL is usually suspected by the finding of low cholesterol] . ce s..a. i_in .31 —._ ,.-..-“ non-alcoholic steatohepatitis (NASH). —‘—nfl——I—--. levels in patients with hepatic steatosis. Past medical history was notable for celiac disease controlled with gluten free diet. Conclusion Never used alcohol. No family history of liver disease. Physical exam was unremarkable besides BMI 31.9 kg/rn1. - Patients with evidence of hepatic steatosis and low tested familial Labs as noted in the table. Workup for chronic [ver disease cholesterol levels should be for was unremarkable. hypobetalipoproteinemia. Liver biopsy showed NASH with stage 2 fibrosis. • Patients who test positive should be referred for genetic Genetic Sequencing of ApoB gene showed heterozygosity , counseling and testing of family members to identify those II Lke M liver disease. (or a splicing mutation. who may be at future risk for chronic

Higher purpose. Greater good: _____

4 INTRODUCTION 4 IMAGING N DISCUSSION______• Acute rhinosinusitis is Fairly common in the pedralric population. Rhabdomyosarcoma accounts for approximately 4% of all pediatric accounting for approximately 1 .6 million office visils per year, or 1% cancers. of all visits for pafienls 0-20 years • Pedtalncians are well equipped to recognize the presenting signs of • Rhabdumycsarcoina is commonly located in head and neck, presenting sirusii 5. including Facial pain, rhinorthea. congestton, and with symptoms including facial swell:ng and prolonged congestion, as headache, as well as twathient with anlibintics. well as eacphthalrnos, neuropaMy, and hearing loss.

• Symptoms ol refractory smusitis. such as headaches and congestion. HISTORY may mask the signs of a enlarging facial mass • To furTher complicate the differentiation, tumors can cause obstiuction A previously flealrhy 9 year old Caucasian Female presents with a 7 and inceease the risk of concurrent and prolonged ,nfection. congestion, worse ors Ihe right side- frontal ‘meek history of bilateral nasal • The development of neurological changes, in his case sixth nerve palsy headache and puwlent rhinontea. Her symptoms slafled shortly after and heanng loss. should misc a red flag to consider underlying returning from vacation in Tennessee where she swam frequently in the Figure I malignancy. hotel’s pooL Oespite multiple completed antibiotic regimens, including • CT and fIRI were hvfpiul in differentiating neoplasttc mass from ctiedamycin, symptoms progressively amoxicillin-clavutanate and infectious mass, while endoscopic biopsy provides a final diagnosis. worsened. She presented to our hoapttal with new onset right sided diplopia for the past week, along with development of partial ageusia, facial pain, • Early evaluation allows for prompt treatment of tumor via surgical debulking and chemotherapy, leading to better outcomes. and pressure.

PHYSICAL EXAM CONCLUSIONS Vitals: BP-92)58, Pulse’64. Temp-97.6 F, Resp.16, Wt-28.3 (39 %ite) • This case shows how similarly chronic sinusitis and nasopharyngual Physical exam was unremarkable except for right maxillary tenderness tumors may present, and the importance of evalual:ng for neurotogic with overlying erythema and swelting, right nasal congestion, decreased changes.

the right eye. - A heightened suspicion of thabdomyosarcoma is warranted during a hearing in lhe right ear- and inability to abduct Figure 2 C Ts,eus sip tumor detiulkiag. sriowirg decrease in tar,, delayed obsthict’ng secarcoes in the nasal caety. prolonged sinusilis course as shared symptoms may lead to I diagnosts and treatment HOSPITAL COURSE DIFFERENTIAL • Facial CT from OSH revealed maxtOary sinus congestion, with possible REFERENCES BACTERL3L SlNtSiTlS ft ‘MiL Sl%USiTis neoplaslic vs infeclious mass and patient was started on ant;biot cs. sixth Ophthalmo!cgy consutfed arid diagnosed patient with isolated .sLLLRt4i(’ mitNiris BESirN TCtuR SW SKI IL BASE nerve palsy • Oaya Ha,.d vi a ‘Fedathc tThdani5cea’seria aI tee Head 4nj lava, hniavca ci & wed Sanee7. eeL 26 Fey 4 22%e *5 • ENT cnr.sutfed and recommended orbital and brain MHI as wefl as a AIRWAY FOFION liOOY t Si ivj\AST NA5nrItSRYMiEt. &.rr’vpvo’-nea’i p TUMOR repeal CT scan, which showed solid enhancing tumor involving the Gdaer Sapdeh aiM Jer,r,,rer J. She. ‘The Suave arc cc. t Pieaaie,xr et Prdiaicr Ctvnr a-awswee,es.’ a’oaerrcowgr-Hreowxuywa eeL IS? ens 25t1 153&teS2 entire nasopharynx extending anteriorly into the postenor aspect of JUVENILE NASSW1IARYNv,tAl. ritrAt THIN Dlsr*[,ERS nasal cavity and nfenorly into oropharynx ANrilorloxuMA Pays Cre’i vi at- ‘Ainei ‘,et ad Teed Fsvin u,j ties cuaie Firma Pulse. are eddnyerrs: Eye OtIS • Patient underwent endoscopic nasal biopsy and panral tumor debulking TENSION HEAN ‘tilEs with bropsy resulls pretim narily srowing rnabdomyosarcoma ReLy 5,ee K ye uJ ‘Rhakde,qosarca,ea ad lead art Neck e LeAker’ OUarpwvdaey need Lt,srFR i iE.WAflIFS TLRHINATF DYSnNc noN .‘eiNcck Sager1, eeL It? eey ?sicna Oil?. • NM anDre body bone scan showed no distant metastasis SINON 55-aL fIANIFaSUONSOF C YStt( I IbeOsiS • Patient was started on a chemotherapy protocol. } _____

The Trickle Down Effect: The Attending’s Role In Resident Lab Ordering Behavior

Paul Kunnath MD, Rachna Rawal MD, Oluwasayo Adeyemo MD MPH, Hala Saad MD, SAINT LOUIS Ara Vaftanyan, Jennifer M. Schmidt MD UNIVERSITY Department of internal Medicine. Saint Louis University School of Medicine. Saint Louis. MO

introduction Results Results mindful •Overail goal: Promoting high-value care & mindful lab Do Residents Worry About Residents Who Have Received How do attending physicians encourage resident ordering habits among residents—need to determine Repercussions From the Attending Pushback From an Attending lab ordering? current state For Not Ordering Daily Labs?’ For NOT Ordering Daily Labs • Resident resoonse: •0 50 • They look at my orders and the lab results for the day • Unexpected finding - Residents identified lear of We make decisions together to remove attending’ as a common barrier to mindful ordering during rounds. 70 to • Project designed to promote high-value care through. unnecessary tests. and ongoing • Attending Physician education on mindful lab ordering SO 00 • Continued positive re-enforcement • Improve attending-resident communication Wt W 4° discussion prompted by attendings Ci 5° C),. em em • Attending resnonse: Methods — — — — • Remembering to have daily discussions with the resident C 40 C We We team 30 em W m 20 o-W 20 10 Discussion • Resident + • 16 weeks • Pre & Post- 10 • Limitations Attending • Multiple intervention Pro Post Post rates physicians on concurrent Surveys Pr. Post Post ‘Variable survey response S Monthsl Y.ar inpatient interventions - Post-Surveys S MDnihsl Y..r New PGY-1 in post 1 year data Survey Response Medicine at6 months Survey Response • Predominantly PGY-3 rotating on inpatient service and 1 year medicine, skew data? Resident and Attending Perceptions • Discrepancy between attending/resident perception Resident Attending ‘Each group feels they initiate majority of Interventions Survey Response Response Response discussions on labs • Attending perception of any discussion + Pre Post Post Post Pre Post Post Post rtfl..,zFfllnrrt attending-initiation markedly higher than l6Wk 6Mo lyr l6Wk GMo lyr • Data showing residents. residents • Actual lab ordering practices ‘Variable expectations? ‘Feedback phenomenon” • Reported perceptions of attendings Report attendingresidenL 25% 46%* 61%’ 41% 78% 78% 100% 89% ‘Cultural shift? • Discuss project goals, interventions discussion of mindFul lab • Fewer residents report worry of attending ordering “more than hail repercussions, increased attending 5FJ the time” encouragement

o Distributed via email and team-room posters • Increased pushback from attendings - due to Report team discussion 25% 79%’ 85%’ 71%’ -- -- — — increased change in resident of what labs to order discussion vs ordering practices

Report team discussion — 76% 79% 70% -- 100% 100% 100% - Weekly email reminders to other attendings to discuss • Sustained change? lab orders of rationale behind Yes, cultural shift, increased discussion

- Provide reminders in regular hospitalist meetings diagnostic testing

Report attendings initiate .- 27% 52% 34% 72% 78% 100% 89% Free Responses-Attending Physicians Next Steps mindftjl lab discussions • When we overuse labs, it causes downstream effects on • Incorporating reminders in attending orientations Report residents initiate -- 69% 69% 55% -- 50% 75W 31% the system. If we am more focused on our lab ordering, it • Increased encouragement during intern and senior boot mindful lab discussions frees up phiebotomists to be able to run the labs that we camp to promote these discussions need, when we need them. It also can allow our patients Report attendings 35% 76%’ 75% 55%’ -- 94% 88% 88% ‘Assess culture after implementation of high-value care more hme to sleep. encourage mindful lab curriculum • Em well aware that how we teach residents to practice now ordering “more than half predicts how they will practice for the next 10-15 years the time” -z::::::zzzzz::’ Having great benefits for patients in the future. p<0.05 Higher purpose. Greater good. —p High-Value Care Education for Third-Year Medical Students Paul Kunnath MD, Rachna Rawal MD, Jennifer M. Schmidt MD SAINT LOUIS . - UNIVERSITY Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO

Introduction Results Results

• Develop high-value care habits during training • Student responses: what are barriers to practicing as these will set foundation for life-long habits high value care as a medical student? • What do SLU Third Year Medical Students •“ Lack of knowledge of what tests are necessary know about high-value care? and for what indications” • “Lack of experience” • 80% not familiar with ‘high-value care” • “Pressure to cover all bases” • 100% had no prior education • “Hard to argue against better safe than sorry, practice habits • Help establish patient-centered especially to a superior” Low value Culture Habit Limitations • Data is survey based Do Students Feel Comfortable Using EBM • Last clerkship group data pending Curriculum Objectives to Make Testing Decisions?t • Early recall bias 100 • Overall lower post-survey response rates • Define ‘high-value care’ •0 0 • 6th • Identify importance of value based healthcare £ ‘i, S0 month and end of year surveys pending 70 • Recognize low value care practices Conclusions C ‘C • Utilize evidence based medicine to apply high On, 50 • Students had minimal prior exposure to value based principles value care 4, healthcare • Spec/fically for lab testing — m on, • Completed online modules but still discrepancy in • Apply clinical reasoning principles knowledge sessions: Methods • After two didactic Pro Post • Increased confidence in application of evidence for Do Students Feel Comfortable Discussing decision making Testing Indications with Team?t • Increased engagement in high value discussions 100 with treatment team 90 •3rd year • Introduction Pre & Post 0 Next Steps medical to high-value clerkship SO students care surveys TO • Address student identified barriers C • Rotating on • Case based • Medicine hierarchy hinders discussion . 50 lM clerkship interactive . • Reduce formal lecture based didactic session 40 • Expand curriculum to other clerkships 30 00 • Include high-value care assessments in student presentations an c ‘“t,,eo cJRR1fl T.-.,g 5.q,a.” Lee,e, Cat t, P.n,o P,,, in’ Me JAMA 22,4,12:2123057303 2 .‘ -“‘ L, —.1 • Formal evaluation of high value care principles •‘4y 023-3’ S 1.’4Ø -Ole,. 0 o’ Ce.. C,nacnC.a., , eon U.. C,Rtho, A Th,,14 Pro Post ‘p <0 05 • NBME shelf examination A0J 0•R 1Xt2t0tQl 451 A Higher purpose. Greater good.” ______

CHARACTERIZATION OF RISK FACTORS AND PRESENTING SYMPTOMS OF MALARIA AMONG CHILDREN IN A RURAL COMMUNITY IN WESTERN KENYA Megan Ottomeyer MSc., DO .t75

Abstract Pediatrics Overall Malaria - No Malaria Overall Presenting Symptoms in Children go Malaria is common and sometimes lalal illness endemic to sub’Saharan GI Symptoms 62 40 Africa. The disease burden of malaria in this area is increased particularly in No GI Symptoms 41 56 — children, making prompt diagnosis and treatment of malaria vital to so. impmving child health. Often, limited access Co medical care is a barrier in OR 2.11; P = 0.01 rural diagnosis and treatment of malaria in these areas, particularly in Respiratory Symptoms 38 32 70 chart review study of tgg I regions of ssjb-Sahamn Africa. This retrospective children (ages birth to 18 years) presenting for acute clinic visits to a No Respiratory Symptoms 65 64 communiry health center located in rural Western Kenya seeks to further 60 — the understanding of clinical presentation of malaria and risk factors OR w 1.196; P = 0.6568 associated with the disease specific to children, Of these, 103 children were Neuro Symptoms 51 26 0 I diagnosed with malaria, based upon rapid antigen testing or peripheral blood smear and light miottcopy. Presenting symptoms wee categoriced No Neuro Symptoms 52 70 by organ system and prevalence of presenting symptoms were compared .1 OR = 2.64; p = 0.0014 I based on age. Among children diagnosed with malaria, frequency of respiratory, ear/nose/throat, and neumlogical complaints varied significantly Skin Symptoms 25 45 by age group. In addition, number of organ systems Involved in symptoms 301111 alto varied by age tignificantly, and age in bush the 2-5 year and 5-10 year No Skin Symptoms 78 51 20 • I_ age groups was found to be associated with increased risk of malaria. This OR = 0.36; P = 0.0011 study is important as it provides guidance for pediatricians working in rural sub-Saharan Africa to be judicious in their use of often limited resources in Symptoms 10 8 101111— — — — diagnostic work up for malaria, as well as providing a deeper understanding MSK of clinical presentation and prevalence of malaria in children based on age. No MSK Symptoms 93 88 .. Fever SI EOST IIReap. MSK iiSkin Neum. OR = 1.18; P = 0.8 ii •i Matar,a Background 25 37 ‘alar,a S No Ii ENT Symptoms NeurologIcal Symptoms Malaria No Milaria 219 million cases of malaria Worldwide in 2017 No ENT Symptoms - 78 59 • 7 every second for 1 year 10)3 years, Nruro symptoms 13 - 7 cases P = 0.D33 OR = 0.511; 1013 years, Na Nsuro symploms 3 10 ‘ 01 concentrated in Sub-Saharan ‘ I BB/a malaria cases worldwide Africa OR =6 19; P 0c32 435.000 deaths worldwide from malaria Average Age in children With and Without Malaria t4- = IS years, Mourn symprmos. S • 205,000 deaths by malaria in children under age 5 7-4 14 <18 fears, rio Neum syinpemiw 1% 4000 child deaths in Kenya per year due to malaria 7.2 05 20: P 0.0033 Symptoms Malaria No Malaria 27% prevalence in children 6m-14y in Lake Endemic region 6.8 (NT Increased risk in rural populations, poor populations >6.6 <2 yea,,, rNT symptOms ID Severity depends on species, strain, genetic factors, nutrition - 5.4 <2 years. Na tNT 14 status, malaria- specific immunity, previous exposure to malaria 6.2 OR = 0 1077: P = 0.03 <6 drugs 5e s.s year,, HIT ,ynwootsw 8 11 5-9 years, Iso tNT sympCmin 22 6 56 p — 00071 —en— Maiana No- Malana OR — 0, tea; Shin Symptoms Malaria No Malaria Systems Involved in Presenting Symptoms Among Children to-ta years, Skin symptoms 1 With and Without Malaria 50-53 years. No skin symptoms Is so = 3.1 OR 0.095; P = 0.0380

A - 00 03 14

An Unusual Case of Pediatric Abdominal Pain 4’h& SSMHeaICh Kyle Hawkins MD, Aline Tanios MD Cardinal of Pediatrics SAINT LOUIS St. Louis University Department Glennon St. Louis, Missouri Children’s Hospital U N I V E R S I T Y..

— EST. iBIS —

Clinical Presentation Discussion 15 year old with history of chronic abdominal pain presenting with Median Arcuate Ligament Syndrome (MALS): Also known as Celiac worsening epigastric abdominal pain. Described as sharp, lasting 3D- Imaging Artery Compression Syndrome. 60 minutes 3-4 times per day, post-prandial, radiates to bilateral • MALS is a cause of chronic, recurrent abdominal pain from upper quadrants. Remainder of review of systems was compression of the celiac artery from the median arcuate post-prandial abdominal unremarkable. Endorses irregular menses since Implanon placement ligament (Fig. 3). It classically causes pain, weight and occasional abdominal bruit. 1 year ago. History of anxiety and on Wellbutrin for the past 2 years. loss, • Diagnosis is established by CT/MR Angiography combined with Parents divorced 2 years ago. Social and family history was otherwise duplex study with respiratory maneuvers. Systolic Flow velocity is unremarkable. elevated during exhalation and normalized during inhalation. Treatment involves celiac artery decompression via resection of Previous Hospitalizations: the median arcuate ligament. May be done open or 18m.pnthrior: Similar symptoms and was found to have elevated laparoscopic. Division of overlying celiac ganglion nerve fibers is lipase and treated with bowel rest and pain control for presumed commonly done to address potential neuropathic causes of pancreatitis. pain. Moority of patients have immediate post-operative pain 1511, weight loss noted since 1month.pç: Similar symptoms but relief. Late recurrence rates are 5-10 percent. enzymes first hospitalization. Basic labs and pancreatic ‘I Alarni findings concerning for organic causes of abdominal pain unremarkable, CT abdomen/pelvis showed thickening of the walls of History: fever, involuntary weight loss, pain with eating, bloody the Celiac and Superior Mesenteric Arteries. Rheumatology was stools, bilious or protracted emesis, back pain, skin changes, A consulted due to concern for vasculitis and an extensive -4 urinary symptoms, family history of abdominal pathologies. - Rheumatologic work-up was unremarkable. She was started on Exam: poor linear growth velocity, oral ulcerations, focal Prednisone and scheduled for CT Angiogram. Hospital Course abdominal pain, arthralgia. Hospital Day ([ID) 1: Started on maintenance IV fluids, resumed regular Physical Exam diet as tolerated. Started PRN Hyoscyamine and Cyproheptadine. ‘Conclusions Vital signs were within normal limits •Median Arcuate Ligament Syndrome is an uncommon and Weight: 77kg (170 Ibs, 95%ile) BMI 28 HD 2: Minimal relief with ‘RN medications. CT Angiogram obtained (Fig. Height: 168cm (56”, 80%ifej 1, 2) and showed narrowing at the origin of the celiac artery. possibly under-diagnosed cause of chronic abdominal pain. Abdomen: Non-tender, non-distended. No masses or ‘Clinician should raise index of suspicion for vascular hepatosplenomegaly. Normoadive bowel sounds. Negative Murphy’s HD 3: obtained Arterial Duplex Ultrasound of the abdomen, which etiologies of CAP in patients with post-prandial abdominal sign. showed elevated flow velocity in celiac artery when supine and during pain and weight loss. Remainder of exam was unremarkable. exhalation, resolving with standing and inspiration. Consistent with -Treatment involves surgical resection of median arcuate Median Arcuate Ligament Syndrome ligament +1- celiac ganglion fibers and has good short and long-term results. Ditte,tni,ai Diarosi. I Supponing or contiiciing evidence in our HD 4: Steroids tapered. Discussed treatment strategies with family, who pat eel decided to proceed to scheduling surgical treatment.

VasL’ Us walls ol Ce,ac WItTY and SMA Follow up: Underwent resection of median arcuate ligament with Resources History atanniery isolution of pain episodes. Retrieved from Fsno,onai Abdarninsi Pen -- I ‘1. Celiac Artery Compression syndrome. https .flwww. a ptod ate. comfcontents/celi ac-artery-corn pression -syndrome. Binary Disease Posi.p,and,ai pa:n 2. Prabhakar 0, Venkat 0, Cooper OS. Celiac Asia Compression Syndrome: A Syndrome of Delayed Diagnosis? Gostroenrerol Heporol (N V). Vascular Compression I Atr.,nnal imag:r.] posi prandial pain 2017;13(3l: 192-194. Enterrococcus faecalis Tricuspid valve endocarditis from lCD lead infection Soumojlt Ghosh, MDt, Bishnu Devkota, MD2 1) Deparimenl of Internal Medione Saint Louis Universrty School of Medicine 2) Division or General intemai Medicine John Cochran Veterans Arlsir Hovpiiat

Introduction Images Discussion older With an increase in the number of implantable pacemakers and defibrilators, the • Enterecoccus spp. are an increasingly prevalent cause of ecdocarditis and can be seen in men following incioer,ce ot cardac imantak’e electronic dev.ce (C1ED).r&aied inlectrors base also ger.-boodray instrumentation. increased [arty ir’eci,cn risk after the p!acemenfcf a CIED is about 1-1 5%’ However. • Diagr,osis’ nE alone is not sensitive enough to esrsh the coirect d agicsi& TEE is irar4aftry to demonstrath as patients are now al4e to live longer a’ter deu:ce implantation, cbron’c leads seme as the presence or absence of a vegetate, on a pacemaker lead ardor valv& a nidus in the setting of sepsis 1mm another primary source. Management of these • TreatinenL parenterat bactencida] antbiocs guided by culture and seruLtivity resu;ts patients proves diftku’t Fse 1’ • For Enterococcus spo. usually 46 weeks of anpici’tin combrned w.h gentar*iri cr slreptcmycn if susoeptie. II ansinoglyco&de revistarre, hen amp;cCin cetiaxon& Case Presentation CXJt Paceflm 5beJa’ai toads over4o • However, in the seffing of CD teads passing ftraçh the in’ecred cardiac valve. antiboft &uató, vanes thia the ng,l flean and jight case by case scenario In a study. median duration of atbot.r fmah,er,f was 2ô days after exjaction of the tead 80 year old mate with a PMH of schemiccardiomyopafry status-Frost CR1-U veehide. {interquwtle range 19.42 days)’ plocemert (in 2012), atrial fibrillation, and COPD who presented with subjective fevers, dyspnea. generalized weakness, and palpitations for the preceding 3 days leads as welt as an unwitnessed fall about 3 days ago. • Management in patients with infective endocarditis with lCD • Prompt hardware removal and prolonged parenterat antibiotic administration decreases modality among patient • Labs signitcantfor WBC 18.1. normocytic anemia 85, UAsuspected for UTI. with CIED5. negative troponins, lactate vest, hyponatremia 129, hypokalemia 3.0. • Consideration of vegetation size will play a major rote in the type of lead extraction performed. II was previously fhoughf that large vegetafions (>10mm) could only be surgically removed (due to the risk of pulmonary • Physical exam revealed a large hemaloma at right hip and thigh, Nasal trauma as embolism), however the presence large vegetations is not a wntiaindication for percutaneous lead extraction well as an irregutarty. irregular rhythm and tINt hctosysfnlic murmur ILSO. and in fact leads to fewer post-removal complications than surgical removal’-4 • Studies with only antibiotic Iheiapy ailed, and eventually required lead extraction’ • Four4 to have CAP a,d E. F*s bactererr4a 2’2 Un Mtibictic re4men gicley • TheroJtinerepenwnfoIthedev.ceshotrecor.sdenedinpalentsinwtxntheiedaboaforpacrigsoo but was started on ceftriasooe and azittvornyc;n and at some po:nf switched to 2 lcnger raid, as there is a sior:’frant risk of reinfection after re.rmpiantacnv Other*ise. studlos reported that new Feure opbonsi earcizosyn. TEE La-ge (11s l0s8 lead placemert can be done after caqoer a7troo trearmer.t w:h lerrpora’y pasnig mm). mobte vegetation

• HE - EF 20% with rio va’vuta thrumalities aitactied to the ateal • Earsydiagr,osis cfapacemaker lead infection isd,tt.cu!L One sintidhesuspiciocs in the case ofapatient with a aspect of sepia] t’.rusrad pacemaker with persis mg bacterem,a and,tr lever without another focus of citectica Eridccasd.tis should be • ATEE revealed a large (12x tO mm). met-ia vegetar cn atached to the anita] value leaf-a: cacs,strri cor.sidemd until proven othe’wis& aspect of seplal tricuspid valve leaflet consistent with entarditis. No vegetation with ectats No vegetavon roted on lead rEFaCE EwEs was seen on the pacer lead wd 3 t,,’•’.EvD.a vd,$—.,eE Akxse initially started on vanc/zosyn which was then switched to ampicilin and t. 1 - rnvi,ie .r. , •E asei 5 e.5Lm, a xiv —fl—— • Patient was — 4_i ••a5_*•_3•__ total cf 4 weeks ce&iaxone for — a S iv vs ,-s._ uflifl v,v—_ _ a4 a-c w viWa,i i _.ih,d fla ——ma € ‘v, , 5,P.i _ssfl vl&astr mCI Ci ma • Patient underwent emergent lead extraction after TEE maE,.4vLIa _ 171 Trial of labor after cesarean: How well can we predict success in contemporary obstetrics. William M. Perez, MD, Laura K. Vricella, MD, CHad A. Gross, MD, Tracy M. Tomlinson, MD, MPH Health Saint Louis University School of Medicine, Department of Obstetrics, Gynecology, & Women’s SSMHeaIUh Background Results Results

Prior Cesarean Table]: Predictive factors for successful vaginal birth after cesarean Table 2: Development ol Exploratory Model rotal successful veec railed VaAC for Likelihood of Successful VBAC p nI042 n713 n.269 Unadjusted Adjusted OR Factor — Successful repeat IiiE1ve [FaileisAc PredIctors In MFMU model OR (95% Cl) (95% Cl) VBAC rean A4e() 28.33 5.4 1114 5.5 21.9 ± 5.2 ll Ae(e( (42(0.99-1.04) 0.94l0.93-037) Least morbidity Intermediate morbidity Greatest morbidity Pse-pe.na.ry IMP’ (kc/w’J 31,1 1 7.96 305±1.5 31.1±119 4 wace/ tihekity 0.58 (047090(1 0.46 (0.33-0 45) 1 703)615) 496164 s1 234 tILl) Likelihood successful VOAC central to counseling <-I Height en) 204fl-02-146) lTh ((.04 1041 of His p. we 30(23) 21127) 9(1.3( The Eunice Kennedy Shriver NICHD Maternal Fetal Medicine Units 4970104 ag—I deliwety 431(41.4) 481139) 61 30.99 04.5, weight 1641 090(591-139) 0.99(0541199) in )MFMU)1 predictive model for successful VBAC was published eliot V5Ac 2” (2573 155 (III 43)151 secpto,e.za.Id.ioe.es a 40p29-5.07) 5.15(334-Ill) 2007 & since validated in many different populations. —— h__n — — a 808 t29tI 104616-ti 99)8519 -Cl • In 2010, the Consortium on Safe Labor significantly altered the Other predicaoea Onepea.nchsddefreee, 1335(144796) 239U61-IMI — MFICd: A5C0641,,’.cl,.I..72) contemporary management of labor by redefining protraction and P.rssationaIth.heIeI 051(0 54-0.673 0.2110120.631 — •‘ry a5c5’2,I5..nSw -a’s 2,3 In lies) ‘0’ 11211 634 II Ii (14±9 arrest disorders. Istoy .4 t,bMeG 5,0 075(054-1.141 013)0.11-I 039 __I— lIp-u) 33(3.7) 1490.2) • Longer duration of labor may decrease the rate of failed TOIAC Hn.w,,. 4h644..0 180(252) 345 Ia 4) 64)23-Il 04 and, in doing so, alter the validity of the MFMU VOAC calculator, , Table 3; Adverse maternal and neonatal outcomes haoy,It,Sweo.mi 271)212) (54939) 51(249) —— Maternal Outcomes n(%) 95% Cl G..ttiwnil 35511.1 2344(1 356±5.3 39 Objectives .i. twoobI chnimnionao 85(1.51 6 St — II Ii I 0, &bnhiei 253 (25-2) 21429.5) 15(53) ‘aol no., IInI tnda97ootetetlo 12 LI 054 — (36 Labor management promoting longer duration of labor thdioII ollibe, 407(39.39 262993.4) 145 53.31 ‘an ffynPi!i]sis: Pip,nsm hnoe.thayn 128(12.3) 10331429 may affect the validity of the MFMU VOAC calculator SintS,,.whtlg) 3215 3215 ± 414 3165± 129 .15 6(4.41,51,1, —e 42(49 2.31 — 519 Oslo.. Hn30.,we±llslflid&004llo I Pt USnt.wert,,. II (104) 0.44 — (.68 Ma 6 owe 641’ Primary Obiective HysIwoIeleev 1(1590) 039-027 n(%l 95350 Assess the validity of the model in a perinatal center employing Figure 1: Predicted and observed VOAC success by predicted docile 14.o,. ii Outcomo NKU admission 121(116) 9-66- 1354 contemporary labor management standards. MFMU VRAC according to the model for successful Smis,).APGAS±oe.4l 359341 234.S 500 — a0b’ectives S On. ta 145 reIn 1439010 I,d,ne& F.’rehabe.thy 4)0.4) ±02—015 Exploratory analysis of predictive of VOAC success in the 0b104w4 su*tr N.ee,±lid,att 2(02) 0.01—041 contemporary era 344___ Study Design 70 Conclusions • Retrospective cohort study: All TOLAC since 2011 • Inclusion criteria: Exclusion criteria: • The MFMU predictive model for VBAC success underestimated actual success in the Live singleton gestation Contraindication to VBAC majority of our population, 37 weeks gestation Malpresentation Despite high rates of negative predictors of VOAC success in our study population, 1 prior low transverse CD lethal fetal anomalies VOAC success was similar to published standards. • While we identfied new variables and modified existing variables in the MFMU 1120 23-30 340 40-50 51-50 63.70 71-30 81-90 93-504 OnenatII fl4nal 5)5: Individual predicted VOAC success calculated using model to better predict VBAC success, our exploratory model was less accurate than published regression formula and compared to observed success VSAC pendided wean dwell. anticipated within each decile of predicted success 2: Predicted and observed VOAC success by predicted decile Figure • We identified 7 antenata) clinical factors associated with successful VOAC which to an exploratory model for successful VSAC according collectively performed more favorably than the MFMU model in our population. Model Development: 100 * • Predicted Success • Women undergoing TOLAC managed with contemporary labor standards without Uniwariate analysis: - — I Observed Success the use of the VOAC calculator to determine candidacy had: Maternal demographics & clinical characteristics 90 y2 • Similar rates of successful VOAC compared to published literature - Student’s t-test or Pearson for continuous and categorical 70 II variables, respectively i•] • Higher than anticipated VOAC success Multivarlable analysis 50 I • Similar rates of maternal and neonatal morbidities

- Factors with P <0-2 on univariate analysis & those historically associaed with VOAC success were incorporated using a forward References

stepwise approach I c,sb...WA Lii 3. laMe’ Ml. eilt tweelepoom eta tle’nognco il Ppe45rs &V.5’-lll -thunon ces.,en c*,.e Css’,i tysmd 2047 let (4); alL - Accuracy of the thoss parsimonious new mcdel with the greatest a r.sctnal c,haAs Gcm,1i4 13.1 04Iepwee1we,e4Ih.r.an ,nnndeo,wy4’ 7 .‘flhletqn,yc.e AUC was compared to that of the MFMU del cseseew,. Am 90611.1 ttny4 20)3.219131; (79-93 c,eenspu,a,-, clsrsnt.nwestI,b,e,tthe, 444,.) 040009l0 JMP.Pro software, version 14 (5.45 Institute ‘‘v NC) 21-30 3t40 45-50 5160 6170 7) 80 61-SO 91-l000ver.I I 14,,gIL,,.d,4’ tsat,hflWet.L rIlimsi Cbsnlet,±, - 73)0. (ISIS) 1241-7 vaac p’.dpct. dsucce,s dwell. I; El Outcomes Of Gastrostomy Device Placement In SMHe Congenital Heart Disease Patients ,aro:na!GIennon hr!dTen i Hcp.t5! Hector osel, MD2; Armando Salim Munoz Abraham, MO, MBEE2; Alice Martin&; Katie Dates’: Jin Sun Kir&; Sakina Kazmi’; Jose Creenspon, MD, FAcS, FMP”2; Colleen Fitzpatrick MD, FAG, FAAP’2; Kaveer Chatoorgoon MD, FAcS, FAAP’2; Gustavo A. Villalona, MD, FAGS. FAAP’’

‘Saint Louis University School of MedicineS 2 Department of Pediatric Surgery, Cardinal Glennon Children’s Medical Center Introduction Results

• Malnutrition and failure to thrive are —- — common among children with congenital Variables t Non-cyanotic heart disease (CHD) Sex • Male 33(53.2%) 8 (40%) 0.304 • Female 29(46.8%) 12 (60°k) • Gastrostomy tube placement in these Age distribution ma 47 (75.8%) 16(80%) patients has gained wide acceptance to • 0 -12 0.324 • 1360 ma 9(14.5%) 4(20%) improve long term nutritional status • >60 mc 6(9Th’o) 0 Type of tube • However, outcomes of these patients • G-tube 26(41.9%) 4(20%) 0.077 • G-button 36(58.1%) 16(80%) undergoing gastrostomy placement have Non-cyanotic Cyanotic SurgiI approach been n= 62 not established • Lapafoscnp,c 58 (93.5%) 18 (90%) 0.143 • Open 1(1.6%) 2(10%) Objective • conversion to open 3 (4.8) U Figu,e 1. flow chart of study CQhOrt Operative time 49(35.75) 40(50.25) 0.154 (median, mlii) • To determine whether type of I congenital heart disease affects outcomes of gastrostomy tube placement go-day complication aO0% Hypothesis p=0.019

• Non-cyanotic heart disease patients have 69.0% improved outcomes when compared to 60.0% cyanotic patients a 0 40.0% Method S S 40.0%

Study design 20.0% • Retrospective study: 2010 - 2017 • DID: Non-cyanotic vs. cyanotic patients

Primary outcome 0.0% • go-day complications non-cyanotic CHD cyanotic CHD

Definition of complication • GERD, feeding intolerance, conversion of gastrostomy to GJ tube, wound infection, Conclusion device dislodgement, peristomal bleeding, • Non-cyanotic patients undergoing gastrostomy tube placement had more complications than cyanotic patients hypergranulation tissue, external gastric leak I ______

To Button or Not To Button? Primary Gastrostomy Tubes -- j ii nrdr,c!Glennon sAlNrLouiyNlv.nsirv Offer No Significant Advantage Over Buttons

Hector Osei, MD2; Armando SaLim Munoz-Abraham, MD, MBEE2; Sakina Kazmi, MPH, MA’; ALice Martin&; Katherine Bates’; un Sun Kim1; Janine Myint’; Kaveer Chatoorgoon, MD, FRCS, FACS, FMP”2; Jose Greenspon, MD, FACS, FMP1’2; CoLLeen Fitzpatrick, MD, FACS, FAAP”2; Gustavo A. ViLLaLona, MD, FACS, FMP”2 ‘Saint Loots University Schl of Medicine - Department of PedIatric Surgery, Cardinal Gfennoo Children’s Medical Cenwr

Introduction Results Discussion

• Gastrostomy device placements are standard practice for Total patients 153 (8%) of study cohorts with complications within 90 long—term nutriLional support. fl 265 days • They are offered to sside spectrum of pediatric patients.

were infants and <10 kg • They are safe and provide improved qtmlitv of life to patients • 64% 72% and parents. • Most institutions now place gastrostomy buttons primarily. • IJaparoscopic technique was the most preferred surgical • However, direct coniparison between prinlatn’ tithes and approach for both devices pnniar’ buttons lots ken established.

• Convenio,i to open technique was signthcanlh higher in i-ig I: tin’ dud ,f udy cution Objectives primal) tubes

To compare outcomes of patients undergoing pdman ttthes vs • No difference in overall or major complication rate between Table I: Study demographics chamdeHslio priman’ buttons Primal) tubes and buttons Variables 0-tube 0-button p-value Sex, n (%) Hypothesis mate 6o% 51% o.,Oç Conclusion Age distribution, n t%) 5’yi Pritnan gastrostomv tube placeownt leads to improve outcomes and O - 12 COO áu% O.3t0 ‘eighI distribution, n (%) decreased complications • Prin,arv gastroslomv button is as safe as pdman o-iu kg C

Operative lime. mill gastrostomy tube mean (SD) 65(43) 56(39) 0092 - Methods • L-ipamscopic approach shutild be surgical approach of Surgical approach, ii (%) Mi% 96% . . . - la1umsospie in pnnsan’ button placement 33000 choice especially gastrnsh’mv utwti

- - - Stsielv Desian tap comeded to open • Pnn,an placenseut of either devsce should 1w tiased un • Retrospective chart renew surgeon’s preference and patient’s characteristics • 2010—2017 P 0.192 0 268 Bibliography Exclitsinn criteria PEG tube placement 55% Si’ ,—, • 2_I ••,- ifll C_aa’ ava.’ • 13 ‘D — a — i ta,ne. #4 b — • —

• i, ,.,, Eb’,t.a23 ,U I 52, otitcame ‘5 ,,#2a.523 Prin,an 5. La -J Ci — — CA P—I - ,.iP,esa — — fl ,__.5- 2i OaC’#4U5’I, go-day complication p—u.— ( 4)C P__o_,_ra. .-A,sn.,3a-fl conversion to &J tube, La. i-23L Minor: GERD, feeding intolerance, 4% • ,,.. ._,L 55.22 54 S•2•.23C.C C,2n4 5C .,Z., wound infection, device dislodgement, perislomal bleeding, 0a. ,s s s,- , —— , • , , ae, S F, 23 53.52 — 5— leak c..a3. •I l,ypergranulittion tissue, external gastric • — 2 L2 L’5 C.-.1a3 Sac.. 1s 2.,as Tan L•3.nl . — .—— .ean —— , o Major: complication requiring NPO/’FPN and/or stirgen’ —cr—— — 2: Prnakaofa,nplicalia,n talown pn,ian’iu hn and balkus ______

Correlation between Postoperative Sonographic and Neonatal Lower Extremity Movement ‘V after in utero Repair for Meningomyelocele: A Day by Day Account / Cord na SAINT LOUIS UNIVERSITY . “Z Glennon — Chase Pribble,1 Cara Buskmiller MD,2 Joanna Kemp MD,3 Catherine Cibulskis MD,3 Allan Fisher MD2 154 iAu Lk*,,,wy 5d’d ,l P—en. I eons ,40e.. Geeobn. LW,p.r,sPfrls! 3 o,renr.*ta p.—,,. Abstract I Objectives Results Otlettive: • Compare [EM pre and post-operatively from open MMC repair Lower extremity movement (LEM) in fetuses undergoing prenatal • Assess for variation in LEM perioperatively Patient Demographics myelomeningocele (MMC) repair is generally assessed at a neonatal • Associate LEM in utero with neonatal evaluation of LLM Age (N=41) Mean GA (SD) evaluation (NE). Ultrasound (US) can assess LEM antenatally, but the Initial Visit 22.09(1.5) correlation between US and NE is not firmly established, nor have L 24.63 (1.1) differences in US findings on different postoperative days (PODl been P000 correlated with NE. Study Design 32 week Evaluation 32.17(0.7) Neonatal Evaluation 34.92(2.6) Study Design: Study Design: Data are presented as mean and standard deviation. • Prospective cohort correlation study This was a prospective cohort correlation study of fetuses that underwent myelomeningocele at SSM Cardinal Glennon Fetal Care • Compare sonographic lower extremity open repair of Movement at the ankle at the initial prenatal visit was attociated with Institule. St Louis MO between January 2021 and December 2016. movement before and alter open fetal function in the same joint on neonatal evaluation Movement of the lower extremities at the toe, ankle, knee, and hip of MMC repair each leg were assessed by US at the initial visit, aher open repair on POD • Assess for variation in sonographic • Us of the aokle and knee on P003 was strongly predictive (k=O.710, 0.420. 0-5, and at 32 weeks gestation. After delivery, NE was performed by lower extremity movement 1.000 and liv 0.577, 0.152-1.000. respectively) perioperatively physical therapists and a neurosurgeon, with 94% occurring In the firtt US of the ankle on POD 4 was alto strongly correlated with neonatal lower ettremity movement in month of life. • Correlate movement of the ankle fk=0.659, 0.308-1.000) utero with neonatal evaluation of lower Results: extremity movement Any [EM varied by POD: it wat present on POD 1 in 45.2% of fetuses who 41 fetuses were included. Follow-up was 100%. Movement at the ankle at showed neonatal movement, and increased to 100.0% by P005. the initial visit was associated with function in the same joint on NE. US of the ankle and knee on POD 3 were strongly predictive (bUilD. 0.420- Data Analysis 1.000 and k= 0.577.0.152.1.000. respectively). Ankle US on P004 was also strongly correlated with NE of the ankle (kro.659, 0.304 1.000). Any • As presence of movement is binary, Cohen’s kappa coefficienis were calculated to Conclusion [EM varied by POD: it was present on POD I in 45,2% of fetuses who atsess the agreement of ultrasound with physical exam after birth. of in the knee, ankle, and toe in showed neonatal movement, and increased to 100.0% by PODS. A p-value ofo.01 was deemed significant. Postoperative US assessment movement fetuses undergoing open fetal MMC repair correlates wilh neonatal evaluation Conclusion: • P003 assessment at the ankie and knee are strongly associated wifh neonatal Postoperative US assessment of movement in the knee, ankle, and toe in joint function repair with NE. POD 3 Results fetuses undergoing open fetal MMC correlates LEM increases between POD land POD Sin fetuses who will have neonatal with assessments at the ankles and knees are strongly associated movement neonatal joint function. LEM increases betv,een POD 1 and POD Sin • Post-operative US of LEM can be a useful predictive evaluation of neonatal tetuses that will have neonatal function. Correlation of Ultrasound with Birth Assessment movement Background Movement Date Kappa, 95% Cl P-value Further study is needed of post’operalive US of lower estremity movement to I Right Toes P003 0.323, 0.052-0.595 .044 assess it as a long-term prognostic factor. • Myelomeningacele (MMC) is the most common neural tube defect P004 0.375,0.083.0.667 .032 pregnancies compatible with life, with a prevalence of 5-10/ 10,000 Left Toes POD 3 0.323. 0.051’O.595 .044 in the United States’ ‘POD 4 ‘0.528. 0.212-0.844 .007 References neurological sequelae include intellectual disability, bowel Common Right Ankte Initial visit 0.590, 0.298-0.882 <.001k and bladder incontinence, and impairment of extremity I. t3ioa CM. Chench*N. Schun j. Mye!ornerrngocele:o ieview ot toe P002 0.396. 0.124-0.668 .015 epemioiogy. genefts, nut onion icr conceptIon. rreno1olaIagn, ond movement3 IPOD 3 10.710, 0.420-1.000 .001 prognosis Inc oiiecied individuals.Obstel Gynecol Surv. 21: 62:47i-9. The Management of Myelomeningocele study (MOMS) showed 2. Avogliono 1. Mosso V. George TM Gureshy S. Builomante GP F’nneliRH. Overview IPOD 4 0.659,0.308-1.000 .003 * choraci eitsfics. tilh that fetal MMC repair is an effective treatment option for an neural tube deiecfs: From development to physical 32w GA 0.679, 0.346-1.000 .001 Defects ten. 2018 Nov 2. Epub ahead ot print. myelomeningocele, and can serve as means to preserve Adoick et ci, Idol ot Prenatal versus Poxinotal Repoi ot 0.415, .011 3. A Randomned neurological function Left Ankle Initial visit 0.080-0.750 Myeiomeningoceie. N EnglJ Med 2011:364:973-1004. OF, Meiners P4. Precbtl HF. So, AC. the influence ot prenatally ‘P002 0.396, 0.124-0.668 .015 4. gaol DA. travwer LC. Soser LFM can be seen on mavemer,ts upino bitido POD 3 0.710, 0,420-1.000 .001 cerebral malformations on the quality at general in ultrasound (US), but lower operta. Eu, J Pediotr Sum 20O3:IlcSvppi. :521 30. exlremity movement (LEM) is POD 4 0.659, 0.308-1.000 .003’ 5. Sl,oi DA. von Weerden tw, vies j limmer A den Dunnen WFA. Stool generally assessed on neonatal 32w GA 0.775, 0.479-1.000 cOOl’ sch,e:nemochenWFA. ei of. Ideonaiai iossc’ r:c-r tuncilon in human np’no br8da cowls. Ped,ofrscs 2004 114:427—34. evalualion-3 tigiit Knee P003 1O.577. 0.152-1.000 .008 6. E.00baa S. Gidehaus AM. Moi:hew Jr AttIc Vlostos t. Fist 60 le:oi in jiera thaI The association bttween prenatal P00 0.152-1.000 .008’ my&onenSngecele repoin at Soni louis Fe’ se inst,luie Ii lee post-MOMS Left Knee hyaiocephoiustrealrnent oufcomen Ic- :opic Tt*d ventricutosiomy vests [EM in the perioperative period, era: Oata are prevented as Cohen’s_kappa and confidence interval. ver.tdcub-pnifoneai shunil. Ch,’di J, 5 y.13. f 151-1168.

and on neonatal evaluation, has Soeciol tI artsic Dr. En,on-jei v:aio’ e Mc . 1 R&ne, tatIe Francis. and

not been clearly defined eva-yore svo’ved a the cae ci the Feioi Co- - Both ______

Head and neck melanoma incidence trends in the pediatric, adolescent, and young SAINT LOUIS UNIVERSITY adult population of the United States and Canada, 1995-2014

Haley ‘4 Bray, MDI Mauliew C Simpson. Miii) Zicaasha S lahirsha. 1152, Jennifer V Bñnkrneier, \fDl,3; Scott C \%aicn. ‘ID, FRCS1Ci 14. \osavaba Orazitwa-Peicts, BDS. PhD, MPH, CHESI56 I Si Lows 1k,ny Sasa 04 18a,, rquthnet & mraoças-H..d Md Na salaT. S... sa’s, 5 ?S.fl La.I W essy S-tsd 04 Hw, sat L’tS F ISad LSt’S LWear 501.0450 M,OSat Drpat’o04 50 Gaaysgobgy slat.’,, *4&a S045ey, canie. — P.aat,,c rosIayolT, San Len. 0 4 54,4 Len Ln..aa-ty acad 50 M. 0,04 fla ad t,cattle. soy”, 554..— Len iaeMy Crre Ca-sot, St Ian. 0 6S.nLca.wn,nayCs0fl.arS5ccH.a,aSoott.zx,. D.prmn* 50 Ep1.-ffwt5’, al 5-t,N.zs, Soi .an, ii)

Background Results • Skin cancer is the most commonly diagnosed Figure 1. Melanoma overall by country Figure 4. Melanoma in US by Race and Ethnicity. cancer in the United States and Canada. 0-65 1.2

96,480 new cases of melanoma are expected in 060 1-0 2019, a 54% increase over 2018 0-55 _—C - • • • About 1 in 5 cases of melanoma are in the head and neck. IR Per - 0 — I00.000FY / :;z The S-year survival rate in head and neck melanoma is worse than other anatomical sites. / • There is limited information about the incidence of E 0-0 melanoma in the pediatric, adolescent, and young fl O 1- 0) 0—flfl5) car- a o — 04 C’) 030 ai0)maa00000 0000 adult (PAYA) population. 1995 2000 2005 2010 ‘995 2000 2005 2010 2 ! Year of Diagnosis Year ol Diagnosis Objective Both Counthes Canada — tinted Slates Hispanic - Non-Hispanic While Non-Hispanic BtacwOlher • To describe melanoma incidence trends in the PATh population in the United States and Canada Figure 2. Melanoma by country and sex Main findings: 0.70 • 12,462 cases of head and neck melanoma were l-Iethods 065 diagnosed between 1995 and 2014 with an age 0.60 Data Source, Study Population, and Study Design ‘; adjusted incidence rate of 0.51 per 100,000 person o ss • Data Source: North American Association years 0.00 / of Central Cancer Registries (NAACCR) Cancer AA1R For / • The incidence of head and neck melanoma in North North America (CiNA) dataset from 1995-2014 100,00OPY in 0.40 America has increased by more than 50°/a in the last Study Population: Patients ages 0-39 -:-;“- . two decades. with melanoma from 1995-2014 in the 0.30 White males ages 15-39 were the main drivers of United States and Canada 025 the increased incidence trend. Study Measures 0.20 199520002005 2010 995 2000200520101995200020052010 Primary Outcome: Melanoma diagnosis Year of Diagnosis Implications • Independent Variables: country, age Both Countries Canada united Stales Most current efforts taken to reduce melanoma at diagnosis, race/ethnicity, gender Male — Female prevalence are focused on indoor tanning bed use and the risk in minors and young adolescent females Statistical Analysis Figure 3. Melanoma by country and sex • Our findings demonstrate a higher incidence of I.0 - Age-adjusted incidence rates per 100,000 person- males which shows the importance of tailoring risk years (PY) 09 -e in a gender- neutral manner 08 t_-’ • •- mitigation measures Incidence rate ratios (RR) with 950/s confidence intervals (CL) AAIfl Per -. Limitations 0.5 • Joinpoint regression - 100000 PY 04 Lack of race information for Canada estimating increases/decreases in age-adjusted 0.3 • There were fewer than 25 cases for some trend incidence over time for each group through 0.2 information due to the overall low incidence of average annual percent changes (AAPC) —.—-——‘—— melanoma in the PAVA •opulation. 1995200020052010 19952000200520101005200020052010 Countries Canada united Slates Yoar of Diagnosis Information - S Contact —0-14 --—— 15-39

HieyOri - .*Sk.llih.,is..do L— - Mesenteric Venous Thrombosis Masquerading as Small Bowel Obstruction Ahmad AI-Taee, MD1’2; Zarir Ahmed DO’; Adam Dhedi MD, MPH1’2; Mike Giacaman, MD”2 SAINT I 0!,) IS Division of Gastroenterology and Hepatology, 2 Department of Internal Medicine, Saint Louis University, St Louis, MO w. VEPSI’Y

INTRODUCTION IMAGING DISCUSSION

• Mesenreric venous thrombosis (MV)’) is an uncommon cause of intestinal ischemia may or • It is important to consider MVT in the differential of smatl bowel obstruction Clinical • Presentation is nonspecific and be acute, subacute Presentation chronic CASE PRESENTATION c • 33 yearold female presented with abdominal pain, nausea, vomiting ‘zj t:_ • Intrebdominal inflammatory process • No surgicat hx, medications (contraceptives, NSAID5), illicit drug usage • Hypertoegufable stale Maignancles, an-a mutation, • Physical Exam Risk Faors myploprolitentive disorder, proteIn C/s deficiency, • Tachycardic, periumbiliral tenderness w/o rigidity or guarding ixothrombns geew mutation antirhromtrn It deficiency • WBC 10.8 109/uL, FIb 9.3 g/dL, Normal lipase, urinalysit, CMP ffL • Course ‘ASz triage S Pus her’ei.scop, ‘s g mu’Lplejw,unal Image 2 surgra I small bowel tropics U cers and a fore en lcd1 showing inravas,a,Iar ‘hrombcsin a arrgiography — reveals venom fillrng defects or lacicof 0• Initial Cr revealing enteritis with small bowel thickening w/ dilation (circlel with s gns of early re (low In me sentenic veins during venous phane • EGO. colonoscopy unremarkable cana sat on (arrow) Diagnosis • Associated wt bowel wall nhekening, mesenteric • Conservatively managed (bowel rest, antibiotics), but sa worsened stranding. asc,tes • Push enteroscopy showed jejunal begoar, causing near small bowel obstruction -) Transferred to SW for becoar removal

li • Push enleroscopy showed multiple gastric and jejunal ulcers and foreign Conservative — anticoagulation, bowel rent. hydration, bowel decompression body mid-jejunum (Image 1), but could not be dislodged Treatment • Surgery indicated for bowel infarction • Started steroids 4 Improved abdominal pain initially 95s worsened 4 C abd concerning for small bowel perforation in mesentery • Emergent exIap with small bowel resection, primary anastomosis • Course complicated by left lower DVI • Our patient likely subacute superior mesenteric venous thrombosis ‘+ bowel • Small bowel bx showed mesenlerir venous thrombosis (Image 2) wall edema, ischemia 4bezoar formation 4 small bowel obstruction”) • 2nd review ofCT scan from 051114 weeks ago) revealed superior perforation mesenseric vein occlusion (Image 3) • This case emphasires the need to consider mesenieric venous thrombosis in • Started on anticoagulation and sent home the differential for atypical cases of small bowel obstruction Diagnosis: Mesenteric venous thrombosis causing small bowel obstruction •i,ierrs I complicated by small bowel perforation lequiring partial small bowel reseclion • se&A..psr..siM&i,,,.. I we..ver,eve.. kuvvcIrsvsti, .alale,ii,a —‘— lmaee 3: CT abdonr : - enseri c venous thrombosis arrowl Higher purpose. Greater gooti