An Informational Letter's Impact on Parent Perceptions and Understanding of Adolescent Confidentiality

BACKGROUND: Adolescence is a period of rapid emotional, behavioral, social, and physiological change in a child’s development. Evidence is conclusive that teens are more likely to engage and revisit their provider in a confidential setting. Parents frequently express hesitancy or opposition when asked to leave the room for the confidential portion of the visit. Studies have shown that while 89% of parents believe that adolescents should speak to a provider one-on-one, about 61% of parents wish to be in the exam room for the entire visit. The goal of this quality improvement project was to determine if parental perceptions and understanding of confidentiality in the adolescent visit could be improved by providing an informational letter before the clinical visit. METHODS: A letter that defined adolescent confidentiality was created and addressed to parents regarding their child(ren)’s transition to adolescent care. This letter, along with a pre- and post-letter survey, was given to parents at annual adolescent well-visits. The survey assessed attitudes and knowledge related to adolescent confidentiality. The knowledge section asked parents to define confidentiality in the adolescent context. The responses were graded as “correct,” “partially correct,” and “incorrect.” Three Plan-Do-Study-Act (PDSA) cycles were completed, revising the succinctness and clarity of the letter and the survey in between each cycle. This yielded a total of 64 responses between spring 2018 and fall 2019. RESULTS: Across all PDSA cycles, the letter was reportedly easy to read. A 60% and 17% increase in parental favorability regarding adolescent confidentiality was seen in cycles 1 and 2. Letter clarity and succinctness were not correlated with parental perceptions, indicating little association between letter “improvements” and parental perceptions. Parental understanding of confidentiality was mixed. With each cycle, there was no significant correlation between reading the letter and likelihood of choosing the most “correct” answer. However, a 25% and 100% increase in combined “slightly correct” and “correct” answers in 2 of 3 cycles was seen. There was also an average 34% decrease of “incorrect” answers across all 3 cycles. CONCLUSION: An explanatory letter may advance parents’ understanding and appreciation for adolescent autonomy; however, there is room for improvement in both areas, which will require alternative interventions.N

Disseminated Histoplasmosis in an Immunocompromised Pediatric Patient

INTRODUCTION: Histoplasma capsulatum is a thermally dimorphic fungi that is highly endemic in the central and eastern United States. The fungus lives in soil contaminated by bird or bat droppings and is aerosolized and inhaled causing infection. Histoplasmosis is generally a self-limited disease. Most symptomatic patients have acute pulmonary histoplasmosis while immunocompromised patients can have severe pulmonary or disseminated infection. This case emphasizes the importance of considering disseminated histoplasmosis in patients with a fever of unknown etiology. CASE DESCRIPTION: A 10-year-old female with Juvenile Dermatomyositis, managed with mycophenolate and methotrexate, presented to the Pediatric Emergency Center with ten days of fever (T max of 103.7°F) and symptoms of myalgia, fatigue, and anorexia. She had no recent travel or significant exposures and immunizations were up to date. Labs were remarkable for a WBC of 2.7 with absolute neutrophil count of 1100, hemoglobin of 11.9 and platelets of 79. Peripheral smear was consistent with mild leukopenia and marked thrombocytopenia. CRP was elevated to 2.46 and ALT to 69. Chest x-ray was negative for infectious process and blood cultures showed no growth. Due to persistent fevers, infectious work-up was broadened to include testing for common respiratory and gastrointestinal pathogens, Cytomegalovirus, Epstein-Barr virus, Aspergillus, Bartonella, Brucella, Francisella tularensis, Mycoplasma, and tick-borne illnesses, with all results negative. Due to worsening pancytopenia, a bone marrow biopsy was performed which revealed non-caseating granulomas with fungal yeast forms consistent with Histoplasma capsulatum. Histoplasmosis urine and serum antigen tests were positive, as was bone marrow culture. She completed a two-week course of intravenous amphotericin B while inpatient, with continued oral itraconazole for 12 months. DISCUSSION: Disseminated histoplasmosis is acquired by inhaling fungal spores in endemic areas and presents with symptoms of prolonged fever, fatigue, anorexia and hepatosplenomegaly. Common laboratory findings include pancytopenia, transaminitis and hyperbilirubinemia. Typical radiologic findings include diffuse reticulonodular, interstitial, or military infiltrates, however 40–50% of immunocompromised pediatric patients with disseminated disease have negative chest x-rays. Tissue culture demonstrating typical fungal yeast forms is definitive for diagnosing histoplasmosis. Treatment with intravenous amphotericin B is given for a minimum of 2 weeks, contingent on clinical response. When clinical improvement is demonstrated, oral itraconazole is given for 12 months. Timely diagnosis of disseminated histoplasmosis can be challenging due to its heterogenous clinical presentation. This case illustrates disseminated histoplasmosis as an important differential diagnostic consideration especially in immunocompromised patients presenting with systemic illness.N

Factors Influencing Physician Treatment Strategies in Crotaline Snake Envenomation

BACKGROUND: Crotaline snake envenomation is a potentially serious medical condition that affects thousands of Americans each year. There continues to be variation in treatment practices by physicians in the United States despite guidelines establishing the use of antivenom and supportive care as the mainstays for treating crotaline snake envenomation. METHODS: This study sought to determine associations between physician treatment strategies, snake identification (ID), venom effects, bite location and patient presentation. A cross-sectional review of electronic medical records (EMR) for patients diagnosed with venomous snake bites from July 1, 2014 to August 31, 2019 was completed. Data collected from the EMR included: patient demographics, transfer information, length of hospital and ICU stays, snake ID, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities and complications, and provider treatment strategy. RESULTS: Of the 83 patients who met inclusion criteria, 68 patients (81.9%) received antivenom. None of the 15 patients who were under observation (no antivenom) for treatment went to the ICU. These patients experienced the shortest hospital stays (H(2)=16.76, p<0.001). Hospital stays were longest for patients envenomated by an identified rattlesnake or cottonmouth compared to patients envenomated by an unknown snake or copperhead (H(2)=14.32, p<0.05). Rattlesnake envenomations used more vials of antivenom than copperhead envenomations (H(2)=8.76, p=0.01). In a regression model of treatment strategy, progression of local tissue effects was the only statistically significant predictor of receiving antivenom while other independent variables including snake ID, patient age, hemotoxicity, systemic symptoms, site of the snakebite, and patient comorbidities were not significant predictors. Lastly, there was a statistically significant association between treatment strategy and opioid prescription, with 77.9% of patients who received antivenom also receiving an opioid for pain management vs. 33.3% of patients under observation (no antivenom) who received opioids (Fisher Exact Probability Test, p=0.001). CONCLUSION: Envenomated patients are likely to be treated with antivenom if there was progression of local tissue effects. For patients in this study who were bitten by copperheads and unknown snakes, close observation without antivenom administration had favorable outcomes including shorter hospital stays and likely decreased hospital costs.N

ANTIVENOM OR OBSERVATION FOR PATIENTS WITH COPPERHEAD ENVENOMATION?

Retrospective cross-sectional review of treatment and outcomes in patients with crotawline snake bites