Objective: With the change in the cervical cancer screening guidelines, women younger than 21 will not be routinely screened and the screening interval is extended to three years. In spite of the well-received newly recommended guidelines on cervical cancer screening, how many patients will be excluded by the guidelines that may have otherwise benefited from the screening? It is important to look at the trends in the screened population in order to answer this question. Our aim was to determine the effectiveness of the previous policy on cervical cancer screening in terms of incidence of cervical cancer and rates of dysplasia in the population of a tertiary hospital gynecology outpatient clinic. Materials and Methods: This is a retrospective analysis conducted at Rambam Health Care Campus’ gynecology outpatient clinic. Chart-review of all cytology reports of PAP smears performed between the years 2004 and 2010 were evaluated. Data were compared to measure the screening methods and changes to the screening method including the trends in PAP smear testing, results, persistence, and the trends in progression and regression in disease based on pre-determined age groups. Results: The rate of atypical PAP smear test results was 10.92% which was broken down in a rate of atypia of 7.66%, the rate of low grade squamous intraepithelial lesion [LGSIL] was 2.93%, and high grade SIL [HGSIL] was 0.338%.The highest incidence of atypical PAP smear results was seen in the age group 21-25. The highest incidence of LGSIL was seen in under 21 years and 21-25 years. The highest incidence of HGSIL was seen under 21 years. In the under 21 y’s group, there was a wide disparity between those who regressed (14%) and those who progressed (3%). On the other hand, in the 26-30 years group and the 41-50 years group, the trend was towards progression of disease (19.4% and 27%, respectively). Conclusions: Through the results of this study, it seems that not testing women under 21 years old would result in missed diagnoses of potentially treatable precancerous cervical lesions. It is important to factor in the harms of excessive PAP smears and subsequent follow up procedures in order to get a more accurate net benefit from the screening of young women.
Clinical Implications•A previously healthy 13-month-old boy admitted for pneumonia and presumed multisystem inflammatory syndrome in children and other possible inflammatory conditions was ultimately found to have Mendelian susceptibility to mycobacterial disease caused by a homozygous deletion in IFN-γ receptor 2. •A previously healthy 13-month-old boy admitted for pneumonia and presumed multisystem inflammatory syndrome in children and other possible inflammatory conditions was ultimately found to have Mendelian susceptibility to mycobacterial disease caused by a homozygous deletion in IFN-γ receptor 2. A previously healthy 13-month-old Hispanic boy born to consanguineous parents from Dominican Republic was referred by his pediatrician to the emergency room for 7 days of fever and marked leukocytosis of 40 × 103/μL. Two months earlier his parents experienced upper respiratory symptoms with anosmia but were not tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient was subsequently admitted from the emergency room with tachypnea and mild intercostal retractions, normal saturation, leukocytosis, elevated inflammatory markers and D-dimer, and negative SARS-CoV-2 RT-PCR result from a nasopharyngeal swab (Table I). Blood and urine cultures were negative. Chest radiograph showed a patchy consolidation in the right lower lobe. An echocardiogram revealed mild pericardial effusion and hyperdynamic contractility. He failed to respond to 3-day intravenous ceftriaxone, and developed a cough and abdominal distention, for which he was transferred to our hospital because of the concern for decompensated pneumonia and possible multisystem inflammatory syndrome in children (MIS-C).Table ILaboratory valuesCBCNormalOSHAdmitPeakDischargeWBC6.2-15.5 × 103/μL49 (6.5% bands)35.545.317.9Neutrophil %21.3%-69.3%648050.5Absolute neutrophil count1.9-8.0 × 103/μL23.7823.789.71Lymphocyte %17%-63.7%2139.739.4Absolute lymphocyte count1.2-7.0 × 103/μL7.4612.97.1HGB10.3-13.2 g/dL811.29.9PLTS150-500 × 103/μL287689500Inflammatory markers CRP0.0-5.0 mg/L26.7279.2314.244.7 ESR0-10 mm/h81103— LDH170-450 U/L1774450628— Ferritin20-200 ng/mL230236484— Procalcitonin<0.49 ng/mL33.667.9249.21— Uric acid2.2-6.0 mg/dL5.54.76.8— Albumin3.5-4.9 g/dL2.23.7— IL-1β0-5.0 pg/mL1.1—— IL-60-5.0 pg/mL395—— IL-80-5.0 pg/mL38.9—— TNF-α0-22.0 pg/mL95.2——Coagulation/cardiac studies D-Dimer0.00-0.50 μg/mL7.727.659.46— Troponin I<0.03 ng/mLNegative<0.010.02— BNP0-100 pg/mL29.4747.10—Microbiology Respiratory PCRNegativeNegativeNegative—— Respiratory PCR methodFilmArray Respiratory Panel 2—— SARS-CoV-2 PCRNegativeNegativeNegativeNegative— SARS-CoV-2 PCR methodRoche Cobas 6800Roche Cobas 6800Simplexa—BNP, Brain naturetic peptide; CBC, complete blood cell count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; HGB, hemoglobin; LDH, lactate dehydrogenase; OSH, outside hospital; PLTS, platelets; WBC, white blood cell count.Pediatric ranges for patients aged 13 mo within our hospital are provided.Bolded numbers are abnormal lab values. Open table in a new tab BNP, Brain naturetic peptide; CBC, complete blood cell count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; HGB, hemoglobin; LDH, lactate dehydrogenase; OSH, outside hospital; PLTS, platelets; WBC, white blood cell count. Pediatric ranges for patients aged 13 mo within our hospital are provided. Bolded numbers are abnormal lab values. Upon transfer on day 12, he was afebrile, with blood pressure of 113/89 mm Hg and tachycardia, but had normal oxygen saturation and physical examination. Chest radiograph demonstrated right middle and lower lobe infiltrates. Laboratory studies revealed leukocytosis, neutrophilia and lymphophilia, microcytic anemia, hypoalbuminemia, and elevated inflammatory markers and D-dimer (Table I). Repeat nasopharyngeal PCR test results for respiratory pathogens and SARS-CoV-2 were negative, whereas coronavirus disease 2019 (COVID-19) antibodies were positive at a titer of 1:960. His initial presentation of pneumonia had a differential including malignancy, HIV, Kawasaki disease, MIS-C, and/or mycobacterial infections. There were no rashes, edema, conjunctival injection, or mucosal changes to suggest Kawasaki, flow cytometry was not consistent with leukemia, and his HIV test result was negative, though the possibility of lymphoma remained. His presentation coincided with the peak of MIS-C cases in New York City.1Dufort E.M. Koumans E.H. Chow E.J. Rosenthal E.M. Muse A. Rowlands J. et al.Multisystem inflammatory syndrome in children in New York State.N Engl J Med. 2020; 383: 347-358Crossref PubMed Scopus (986) Google Scholar Children with COVID-19 generally do well, with a mortality rate of 0.1%.2Shekerdemian L.S. Mahmood N.R. Wolfe K.K. Riggs B.J. Ross C.E. McKiernan C.A. et al.Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units.JAMA Pediatr. 2020; 174: 1-6Crossref Scopus (728) Google Scholar Worldwide, more than 1000 children who previously appeared healthy were hospitalized for MIS-C.1Dufort E.M. Koumans E.H. Chow E.J. Rosenthal E.M. Muse A. Rowlands J. et al.Multisystem inflammatory syndrome in children in New York State.N Engl J Med. 2020; 383: 347-358Crossref PubMed Scopus (986) Google Scholar,3Whittaker E. Bamford A. Kenny J. Kaforou M. Jones C. Shah P. et al.Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2.JAMA. 2020; 324: 259-269Crossref PubMed Scopus (1425) Google Scholar,4Feldstein L.R. Rose E.B. Horwitz S.M. Collins J.P. Newhams M.M. Son M.B.F. et al.Multisystem inflammatory syndrome in U.S. children and adolescents.N Engl J Med. 2020; 383: 334-346Crossref PubMed Scopus (1769) Google Scholar This child demonstrated the characteristics of MIS-C, including fever with positive SARS-CoV-2 antibodies, elevated inflammatory markers, elevated D-dimer, and multiorgan involvements.5U.S. Centers for Disease Control and PreventionMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19). U.S. Centers for Disease Control and Prevention, Health Advisory Network, Atlanta, GA2020Google Scholar The patient was treated with intravenous antibiotics for presumed bacterial pneumonia, and enoxaparin and intravenous immune globulin for presumed MIS-C. However, he did not respond and continued to have tachypnea, abdominal distention, and elevated inflammatory markers. Marked leukocytosis and lymphophilia were inconsistent with MIS-C. On day 14, a QuantiFERON-TB Gold Plus, which had been submitted, was reported to be positive. An abdominal ultrasound (day 16) revealed innumerable small splenic hypoechoic foci, mild hepatomegaly, and lymphadenopathy in the portal region. He was sedated and intubated to obtain a chest angiography and abdominal computerized tomography, which revealed dense consolidation of the right lower and middle lobes, hepatosplenomegaly with many hypodense splenic lesions, and portacaval adenopathy (see Figure E1 in this article's Online Repository at www.jaci-inpractice.org). Following difficult intubation and the imaging studies, he was transferred to intensive care and remained intubated for 7 additional days. Day 17 bronchoscopy revealed an endobronchial mass obstructing 80% of the bronchus. Tuberculous meningitis was excluded with cerebrospinal fluid studies. Because of positive IFN-γ release assay, splenic lesions, and lymphadenopathy, the patient was started on treatment for presumed miliary tuberculosis with rifampin, isoniazid, pyrazinamide, and ethambutol, and with corticosteroids to relieve the endobronchial obstruction on day 18. A skin test PPD was read as negative 2 days later while PCR results for tuberculosis and repeat QuantiFERRON-TB Gold Plus were also negative. Immunologic workup showed elevated immunoglobulin levels, normal lymphocyte subsets, and a normal dihydrorhodamine test result. On day 21, splenic biopsy showed acute inflammation and ill-defined minute nonnecrotizing granulomas. Bronchoalveolar lavage and gastric aspirate cultures were positive for Mycobacterium avium complex on day 33, and the treatment was optimized to cover for this with rifampin, ethambutol, and clarithromycin, in addition to moxifloxacin for latent tuberculosis infection. These new findings increased the index of suspicion for Mendelian susceptibility to mycobacterial disease (MSMD), and further investigation was conducted to identify an underlying genetic defect. Family history indicated that the parents were second-degree cousins who had no apparent family history of primary immunodeficiency disease, as shown in the family pedigree (see Figure E2 in this article's Online Repository at www.jaci-inpractice.org). MSMD was confirmed, with immunogenetic studies revealing a homozygous deletion mutation in IFN-γ receptor 2 (IFNGR2), at position c.503_504del (p.Thr168Ilefs∗33), a previously reported pathogenic mutation in a child with autosomal-recessive MSMD.6Kamoun C. Morsheimer M. Sullivan K.E. Holland S.M. Cunningham-Rundles C. Bunin N. et al.Successful unrelated cord blood transplant for complete IFN-gamma receptor 2 deficiency.J Allergy Clin Immunol. 2016; 138: 1489-1491Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar He showed clinical improvement after 3 weeks of aggressive antimycobacterial therapy. He was taken off ventilator and supplemental oxygen on day 23. Repeated bronchoscopy showed resolution of bronchoalveolar mass on day 21, and subsequent serial chest radiographs showed resolution of right-sided consolidation. Weekly ultrasounds showed decreased hepatosplenomegaly and lymphadenopathy by hospital discharge on day 55. The patient was discharged home on antimycobacterial treatment and referred for hematopoietic stem cell transplant. Mendelian susceptibility to mycobacterial disease is a rare primary immunodeficiency characteristic of severe and disseminated infections with weakly virulent mycobacteria, such as Bacillus Calmette-Guerin–BCG vaccine strain and mycobacterium avium complex, and in 50% of cases Salmonella species. MSMD can be caused by 1 of the 15 genetic mutations in the macrophage and lymphocyte loop primarily involving molecules in the IL-12/IFN-γ signaling pathways including IFNGR2.7Tangye S.G. Al-Herz W. Bousfiha A. Chatila T. Cunningham-Rundles C. Etzioni A. et al.Human inborn errors of immunity: 2019 Update on the Classification from the International Union of Immunological Societies Expert Committee.J Clin Immunol. 2020; 40: 24-64Crossref PubMed Scopus (858) Google Scholar To date there have been fewer than 30 cases of IFNGR2 reported in the literature. More than half the cases had poor survival. Hematopoietic stem cell transplant is considered curative.8Rosain J. Kong X.F. Martinez-Barricarte R. Oleaga-Quintas C. Ramirez-Alejo N. Markle J. et al.Mendelian susceptibility to mycobacterial disease: 2014-2018 update.Immunol Cell Biol. 2019; 97: 360-367Crossref PubMed Scopus (158) Google Scholar,9Bustamante J. Boisson-Dupuis S. Abel L. Casanova J.L. Mendelian susceptibility to mycobacterial disease: genetic, immunological, and clinical features of inborn errors of IFN-gamma immunity.Semin Immunol. 2014; 26: 454-470Crossref PubMed Scopus (497) Google Scholar At the time of the patient's presentation, MIS-C was increasingly recognized in New York City. He had an initial clinical picture mimicking MIS-C, which is a diagnosis of exclusion. Through microbiology, pathology, radiology, and crucial genetic studies, MSMD was discovered. This case emphasizes overlapping and distinct features of MIS-C and MSMD, which is outlined in Table II. Both diseases present with prolonged fever, cough, and elevated inflammatory markers, particularly TNF-α and IL-6. MIS-C is associated with lymphopenia, abnormal coagulation, multisystem involvement, serologic evidence of COVID-19, but unlikely to have lymphadenopathy and positive bacterial cultures. In comparison, MSMD characteristically presents with lymphophilia, disseminated multiorgan lesions, lymphadenopathy, and positive mycobacterial cultures, and is less likely to have abnormal coagulation and thrombotic events.Table IIComparing MIS-C related to COVID-19 (MIS-C) and MSMDParameterCDC MIS-C5U.S. Centers for Disease Control and PreventionMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19). U.S. Centers for Disease Control and Prevention, Health Advisory Network, Atlanta, GA2020Google ScholarMSMDAge<21 yEarly in childhood and rarely in adulthoodFever≥38.0°C for ≥24 h, or report of subjective fever lasting ≥24 hLikely and can occur with weight lossHospitalizationRequiredLikelyLaboratoryEvidence of inflammation:Lymphopenia, neutrophilia, elevated inflammatory markers (CRP, ESR, IL-6, procalcitonin, ferritin, LDH)Abnormal coagulation (elevated fibrinogen and D-dimer)HypoalbuminemiaLymphophiliaElevated inflammatory markers:CRP, ESR, TNF-α, IL-6Normal coagulationMay have hypoalbuminemiaSARS-CoV-2 presenceAt least 1 required:Positive by RT-PCR for RNAPositive serological assay for antibodiesPositive COVID-19 antigen by antigen assayExposure to a known case within 4 wk before onset of symptomsUnlikely except for current COVID-19 pandemicBlood and tissue culturesNegative—must exclude other diagnosesPositive blood and/or tissue culturesNontypical mycobacteria, Salmonella, Listeria, histoplasmosis, etcChest radiographyNot required for diagnosis but may include opacities (ground glass), peribronchial thickening, and/or pleural effusionsDisseminated pulmonary lesions are commonMultisystem involvementAt least 2 organ systems involved (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurological)Not required but often lymphadenopathy present and multisystem involvement likely with disseminated infectionsGeneticsNot found at presentConfirmed by immunodeficiency screen for mutations in IKBKG, IFNGR1, IFNGR2, STAT1, IL12B, IL12RB1, IL12RB2, IL23R, ISG15, IRF8, TYK2, CYBB, RORC, JAK1, and SPPL2ACDC, Centers for Disease Control and Prevention; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; LDH, lactate dehydrogenase.MIS-C can be diagnosed if no other diagnosis is possible. Some patients with MIS-C may have overlapping symptoms with complete or incomplete Kawasaki disease. Open table in a new tab CDC, Centers for Disease Control and Prevention; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; LDH, lactate dehydrogenase. MIS-C can be diagnosed if no other diagnosis is possible. Some patients with MIS-C may have overlapping symptoms with complete or incomplete Kawasaki disease. We thank all frontline providers, consultants, nurses, and staff of the Kravis Children's Hospital and Mount Sinai Hospital for their care of the patient. We extend a special thanks to Samantha Ganz, MD, and Erik Sanchez, MD, for their assistance in obtaining immunogenetic testing for the patient, as well as Dr Julie Teruya-feldstein, MD, and Dr Christian Salib for the pathology study. Figure E2Pedigree chart. The mother is the daughter of one the patient's father's cousins (a second cousin to the father).View Large Image Figure ViewerDownload Hi-res image Download (PPT)
Abstract Background:The novel coronavirus, COVID-19 was identified in January 2020 initially in Wuhan, China but quickly spread worldwide and was declared a global pandemic by the World Health Organization on March 11, 2020. There are more than 185 countries impacted and the numbers of cases and deaths continues to rise. The rate of coinfections with COVID-19 in children and the clinical implications are unknown.Case Presentation:We describe the clinical presentation and course of three patients with COVID-19 and coinfections with other common respiratory viruses. Two cases were diagnosed with COVID-19 as well as rhinovirus/enterovirus and the third case was COVID-19 and pertussis. Each case had a unique presentations and hospital courses including an emergency room discharge, urgent surgical evaluation and an intensive care unit admission.Conclusions:This is the first US-based case report to discuss coinfections with COVID-19 and other respiratory viruses. Decisions regarding diagnosis and management of children in the setting of the current pandemic should account for the possibility of coinfections. We also highlight publish health challenged resulting from children with the novel coronavirus.
Background: Malnutrition is estimated to contribute to more than one third of all child deaths worldwide, although it is rarely listed as the direct cause. In sub-Saharan Africa, around one in four children is undernourished according to the most recent World Food Program report. By WHO standards, nearly one out of five children who visit a rural Ugandan clinic are malnourished, and just over half are classified as severely malnourished. There is a malnutrition program at the clinic that identifies malnourished children and provides high energy …
Objectives: Social disruption due to COVID-19 has detrimentally affected American adolescents’ emotional well-being. Within our system, pediatric acetaminophen ingestions increased in 2020, compared with previous years. We sought to evaluate the rate of hospitalizations for acetaminophen self-harm ingestions and self-harm of adolescents during the COVID-19 pandemic. Study Design: We identified patients (aged 0-23) from billing data with diagnosis of acetaminophen ingestion with self-harm intent (ICD-10 code T391X2A), from a multicenter urban, quaternary health care system. We performed retrospective chart review from 2016 to 2020 and performed statistics using a generalized estimating equation (GEE) logistic regression model. Results: From 2016 to 2020, there were 25 790 discharges of adolescents with 65 acetaminophen self-harm ingestion and 148 self-harm discharges. Of the 65 acetaminophen patients, 75% identified as female and 54% identified as non-white; 71% with Medicaid insurance. The proportion of acetaminophen ingestion and self-harm admissions increased from 0.13% in 2016 to 0.46% by 2020 and 0.42% in 2016 to 0.73% by 2020, respectively. The odds of acetaminophen ingestion admission increased by 28% each additional year (odds ratio = 1.28; 95% confidence interval: 1.08, 1.53; P = .006). There was not enough evidence to conclude that the log-odds of a self-harm ingestion were linearly related to time ( P = .06). Conclusions: Acetaminophen ingestion for self-harm has significantly increased, while overall self-harm has increased to a lesser, nonsignificant degree. Primarily females of color and those with Medicaid insurance are affected. It is important to note this growing, disturbing trend, and to continue to screen for depression in our adolescent community and ensure access to mental health resources.
