Does presence of a VACTERL anomaly predict an associated gynecologic anomaly in females with anorectal malformations?: A Pediatric Colorectal and Pelvic Learning Consortium Study

BACKGROUND

VACTERL association is defined by the presence of 3 or more anomalies in any of the following systems: vertebral, anorectal, cardiac, trachea-esophageal, renal, or limb. This study hypothesized that the presence of VACTERL association would correlate with an increased risk of gynecologic anomalies in patients with anorectal malformation (ARM).

METHODS

This study is a cross-sectional, retrospective analysis from the prospectively collected, multicenter registry of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The 834 female patients with ARM who were enrolled in the registry by January 1, 2020 were included in this study. The relationship of VACTERL association with presence of a gynecologic anomaly was evaluated with Fisher's exact test. The relationship of each VACTERL system with presence of a gynecologic anomaly was assessed in patients with cloaca, rectovestibular fistulas and rectoperineal fistulas. P-values reported were based on a 2-sided alternative and considered significant when less than 0.05.

RESULTS

834 patients with ARM underwent VACTERL screening and gynecologic evaluation with the three most common subtypes being cloaca (n = 215, 25.8%), rectovestibular fistula (n = 191, 22.9%) and rectoperineal fistula (n = 194, 23.3%). A total of 223 (26.7%) patients with ARM had gynecologic anomalies. VACTERL association was seen in 380 (45.6%) of patients with ARM. Gynecologic anomalies were present in 149 (39.1%) vs. 74 (16.3%) of subjects with vs. without VACTERL association (p < 0.001). VACTERL association did not significantly increase the risk of gynecologic anomaly in patients with cloaca and VACTERL (n = 88, 61.5%) vs. cloaca without VACTERL (n = 39, 54.2% p = 0.308). VACTERL association increased the risk of gynecologic anomalies in patients with rectoperineal fistulas (n = 7, 14.9% vs n = 9, 6.1% p = 0.014) and rectovestibular fistulas (n = 19, 31.1% vs. n = 13, 10.0% p<0.001). In patients with ARM who had a VACTERL association, when one of the associated anomalies was renal, there was an even higher risk of having an associated gynecologic anomaly (n = 138, 44.2% vs. n = 85, 16.3% p<0.001).

CONCLUSIONS

VACTERL association in patients with rectoperineal and rectovestibular fistulas correlates with an increased risk of gynecologic anomalies. The presence of VACTERL associated findings, especially renal, should prompt a thorough evaluation of the gynecologic system.

LEVEL OF EVIDENCE

III. Retrospective comparative study.

Digital photography in the evaluation and management of female patients with congenital adrenal hyperplasia: A standardized protocol for quality improvement

INTRODUCTION

Digital photography can be securely stored in the medical record and enhance documentation of physical exam findings and monitor wound healing. A standardized protocol that respects the dignity of the patient and maintains the fidelity of objective documentation is needed for patients with differences in sexual development (DSD) and congenital adrenal hyperplasia (CAH).

OBJECTIVE

The purpose of this study was to evaluate the feasibility, acceptability, and applications of a HIPAA-compliant digital photography protocol in the care of female patients with CAH.

STUDY DESIGN

A protocol for standardized digital imaging including consent, permission, data capture, and storage in the electronic medical record (EMR) was implemented. Patients undergoing physical examination during multidisciplinary CAH clinic visits, preoperative evaluation, and postoperative follow-up from October 2020 through May 2021 were included. Male patients with CAH, patients with clitoromegaly or urogenital sinus not from CAH, and patients seen through telehealth were excluded. Consent was obtained from caregivers and permission from patients. Images of the exam were taken during clinic visits or at the time of surgery with no identifying features included. Images were directly uploaded into the patient's chart in the HIPAA-protected EMR separate from other clinical documentation and not stored on personal devices.

RESULTS

There were 17 patients with CAH seen with median age 6 years (range 2 weeks-18 years). There was a median of 3 photos per patient during the study period with cooperation from both the patient and their caregiver. Amongst the patients seen, 6 patients underwent reconstruction with a median of 10 photos per patient. Images were available and used for preoperative planning and counseling. Patients with previous images did not require repeat examinations and were subjected to fewer genital examinations. Fewer providers were present during exams. Images taken by providers and caregivers during the postoperative period were used to monitor wound healing and surgical outcomes.

DISCUSSION

Protocol implementation improved patient care by reducing the number of exams and number of providers present, enhancing clinical documentation, and providing a means of tracking the physical exam over time. This was in concordance with guidelines for limiting exams for patients with DSD and CAH. Implementation of best practices for medical photography was important in respecting patient dignity and confidentiality.

CONCLUSION

Implementation of standardized digital photography was feasible and acceptable to patients and caregivers. Digital images reduced the need for repeat physical examination and provided a visual means of enhancing clinical documentation.

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

STUDY OBJECTIVE

The fracture of hormonal implants, including Implanon, Nexplanon (both from Merck & Co, Inc), and histrelin acetate is rare. Our aim was to describe patient demographic characteristics, mechanisms, and consequences of fractured implants by surveying physicians' experience via listservs and social media. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We developed a Research Electronic Data Capture survey for physicians regarding their experience with implant fracture, including patient characteristics, mechanism of fracture, changes in menstrual bleeding patterns, time from insertion to fracture, and time from fracture to seeking care. We distributed the survey to providers in listservs for the North American Society for Pediatric and Adolescent Gynecology, the Family Planning Fellowship, the Ryan Program, and the Facebook Physician Moms Group and Facebook OB-GYN Mom Group. We performed descriptive analyses.

RESULTS

We received 42 survey responses, representing 54 discrete implant fractures of which 70% (n=14) were Nexplanon, 26% (n=38) were Implanon, and 4% (n=2) were histrelin acetate. Mechanisms of implant fracture included patient manipulation (23%, n=12), unintentional trauma (11%, n=6), interpersonal violence (8%, n=4), lifting/carrying (6%, n=3), fracture with removal (6%, n=3), and unknown (47%, n=25). Bleeding pattern was not altered in 78% (n=42) of cases. Time interval between placement and fracture was less than 2 years for 63% (n=34) of cases. Thirty-nine percent (n=21) of patients presented for care more than 1 month from the time of fracture.

CONCLUSION

Patients should be counseled about potential for hormonal implant fracture, advised against excessive manipulation of implants, and counseled to present for care immediately upon noticing an implant fracture. Surveying physicians through listervs and social media is an effective strategy to increase the reporting of rare complications and events.

Use of 3D reconstruction cloacagrams and 3D printing in cloacal malformations

INTRODUCTION

Cloacal anomalies are complex to manage, and the anatomy affects prognosis and management. Assessment historically includes examination under anesthesia, and genitography is often performed, but these do not consistently capture three-dimensional (3D) detail or spatial relationships of the anatomic structures. Three-dimensional reconstruction cloacagrams can provide a high level of detail including channel measurements and the level of the cloaca (<3 cm vs. >3 cm), which typically determines the approach for surgical reconstruction and can impact long-term prognosis. Yet this imaging modality has not yet been directly compared with intra-operative or endoscopic findings.

OBJECTIVES

Our objective was to compare 3D reconstruction cloacagrams with endoscopic and intraoperative findings, as well as to describe the use of 3D printing to create models for surgical planning and education.

STUDY DESIGN

An IRB-approved retrospective review of all cloaca patients seen by our multi-disciplinary program from 2014 to 2016 was performed. All patients underwent examination under anesthesia, endoscopy, 3D reconstruction cloacagram, and subsequent reconstructive surgery at a later date. Patient characteristics, intraoperative details, and measurements from endoscopy and cloacagram were reviewed and compared. One of the 3D cloacagrams was reformatted for 3D printing to create a model for surgical planning.

RESULTS

Four patients were included for review, with the Figure illustrating 3D cloacagram results. Measurements of common channel length and urethral length were similar between modalities, particularly with confirming the level of cloaca. No patient experienced any complications or adverse effects from cloacagram or endoscopy. A model was successfully created from cloacagram images with the use of 3D printing technology.

DISCUSSION

Accurate preoperative assessment for cloacal anomalies is important for counseling and surgical planning. Three-dimensional cloacagrams have been shown to yield a high level of anatomic detail. Here, cloacagram measurements are shown to correlate well with endoscopic and intraoperative findings with regards to level of cloaca and Müllerian development. Measurement discrepancies may be due to technical variation indicating a need for further evaluation. The translation of the cloacagram images into a 3D printed model demonstrates potential applications of these models for pre-operative planning and education of both families and trainees.

CONCLUSIONS

In our series, 3D reconstruction cloacagrams yielded accurate measurements of urethral length and level of cloaca common channel and urethral length, similar to those found on endoscopy. Three-dimensional models can be printed from using cloacagram images, and may be useful for surgical planning and education.

Unexpected ethical dilemmas in sex assignment in 46,XY DSD due to 5-alpha reductase type 2 deficiency

Sex assignment at birth remains one of the most clinically challenging and controversial topics in 46,XY disorders of sexual development (DSD). This is particularly challenging in deficiency of 5-alpha reductase type 2 given that external genitalia are typically undervirilized at birth but typically virilize at puberty to a variable degree. Historically, most individuals with 5-alpha reductase deficiency were raised females. However, reports that over half of patients who underwent a virilizing puberty adopted an adult male gender identity have challenged this practice. Consensus guidelines on assignment of sex of rearing at birth are equivocal or favor male assignment in the most virilized cases. While a male sex of rearing assignment may avoid lifelong hormonal therapy and/or allow the potential for fertility, female sex assignment may be more consistent with external anatomy in the most severely undervirilized cases. Herein, we describe five patients with 46,XY DSD due 5-alpha-reductase type 2 deficiency, all with a severe phenotype. An inter-disciplinary DSD medical team at one of two academic centers evaluated each patient. This case series illustrates the complicated decision-making process of assignment of sex of rearing at birth in 5-alpha reductase type 2 deficiency and the challenges that arise when the interests of the child, parental wishes, recommendations of the medical team, and state law collide.

Long acting reversible contraception in adolescents with cardiovascular conditions

STUDY OBJECTIVE

The purpose of this case series was to evaluate the efficacy and complication rate with use of long-acting reversible contraceptive (LARC) methods in adolescents with cardiovascular conditions.

DESIGN AND PARTICIPANTS

We performed a retrospective chart review of adolescents age 22 or younger with congenital cardiac anomalies or major cardiovascular conditions who had a LARC device placed at Seattle Children's Hospital or University of Washington Medical Center between January 1, 2007 and March 1, 2012.

MAIN OUTCOME MEASURES

Patient characteristics, medical conditions, indications, and complications including perforation, pregnancy, expulsion, and pelvic infection were collected and analyzed.

RESULTS

Thirty adolescents with congenital cardiac anomalies or other cardiovascular conditions had a LARC device inserted during the study period. Mean age at placement was 17.7 years (range 12-22). Twelve patients (40%) had reported a previous pregnancy and 12 (40%) had never been sexually active at time of placement. Common primary and secondary indications were desired contraception (22 patients, 73%), desired menstrual suppression (15 subjects, 50%) and treatment of heavy menstrual bleeding (8 subjects, 27%). Twenty-nine patients had a structural cardiac anomaly. There were 27 levonorgestrel-releasing intrauterine devices (IUD), 1 copper IUD, and 3 etonogestrel implants placed. There were 2 confirmed IUD expulsions and 1 removal due to persistent irregular bleeding and cramping. There were no cases of pelvic inflammatory disease or pregnancies with LARC methods in place. Twenty-seven (90%) patients were continuing LARC at last follow-up.

CONCLUSIONS

In this small case series of adolescents with cardiovascular conditions, LARC devices were effective at pregnancy prevention without serious complications.

Learning professionalism: perspectives of preclinical medical students

PURPOSE

To identify and examine how students respond to and engage with formal professionalism teaching strategies, and what factors outside the formal curriculum may influence professional development.

METHOD

Individual semistructured interviews were conducted with 56 students completing the preclinical curriculum at the University of Washington School of Medicine in 2004 and 2005. Interviews were recorded, transcribed, and analyzed using qualitative methods.

RESULTS

Students identified role modeling as an important modality for learning professionalism, even during their preclinical years. Role models included classroom faculty and peers, in addition to physicians in clinical settings. Small-group discussions and lectures helped some students identify and analyze the professional behaviors they observed, but they elicited negative responses from others. Students believed their professionalism derived from values, upbringing, and experiences prior to medical school. Some students reflected on their evolving professionalism while working directly with patients.

CONCLUSIONS

Medical schools should ensure that students are exposed to excellent role models-ideally, faculty who can articulate the ideals of professionalism and work with students longitudinally in clinical settings. Lectures about professionalism may alienate rather than inspire students. Students' premedical experiences and values influencing professionalism should be acknowledged and appreciated. Bedside teaching and reflection on students' inner experience as they begin to work directly with patients deserve further exploration as opportunities to teach professionalism.