Publications by authors named "Seema Menon"

31 Publications

Long-Acting Reversible Contraception: Specific Issues for Adolescents.

Authors:
Seema Menon

Pediatrics 2020 08 20;146(2). Epub 2020 Jul 20.

Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin

Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.
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http://dx.doi.org/10.1542/peds.2020-007252DOI Listing
August 2020

Biobrane™ versus acticoat™ for the treatment of mid-dermal pediatric burns: a prospective randomized controlled pilot study.

Int J Burns Trauma 2018 20;8(3):63-67. Epub 2018 Jun 20.

The Children's Hospital Burns Research Institute and Burns Unit, The Children's Hospital at Westmead Sydney, Australia.

Objectives: The management of pediatric mid-dermal burns is challenging. Anecdotal evidence suggests Biobrane™ (UDL Laboratories, Inc., Sugar Land, TX) may expedite epithelization, reducing the requirement for skin grafting. Our standard management for burns of this depth is Acticoat™ (Smith and Nephew, St. Petersburg, Fl, USA). No publications are known to compare Biobrane™ to Acticoat™ for treatment of mid-dermal burns.

Methods: A prospective, randomised controlled pilot study was conducted, comparing Biobrane™ to Acticoat™ for mid-dermal burns affecting ≥ 1% Total Body Surface Area (TBSA) in children. Mid-dermal burns were confirmed using Laser Doppler Imaging within 48 hours of injury. Participants were randomized to Biobrane™ with an Acticoat™ overlay or Acticoat™ alone.

Results: 10 participants were in each group. Median age and TBSA were similar; 2.0 (Biobrane™) and 1.5 years (Acticoat™), 8% (Biobrane™) and 8.5% TBSA (Acticoat™). Use of Biobrane™ had higher infection rates (6 children versus 1) (P = 0.057) and more positive wound swabs, although not significant (7 children versus 4) (P = 0.37). Healing time was shorter in the Biobrane™ group, this was not significant (19 days versus 26.5 days, P = 0.18). Median dressing changes were similar (5 versus 5.5) (P = 0.56). Skin grafting requirement was greater in the Acticoat™ group (7 versus 4 children, P = 0.37) and similar in % TBSA (1.75% TBSA).

Conclusion: This pilot study suggests that the use of Biobrane™ for mid-dermal burns in children may be associated with increased risk of infection but appears to decrease the time to healing and therefore the need for skin grafting compared to Acticoat™ alone.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055079PMC
June 2018

Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding.

J Pediatr Adolesc Gynecol 2018 Oct 8;31(5):451-458. Epub 2018 Mar 8.

Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Study Objective: On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We performed a retrospective chart review of adolescents younger than 21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information including demographic characteristics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into 2 categories on the basis of the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared.

Results: Seventy-three subjects were tested for a bleeding disorder. Of the subjects who completed testing, 34 (46%) were diagnosed with a bleeding disorder. Thirty-nine subjects (54%) had heavy menstrual bleeding because of other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without a bleeding disorder. In a comparison of hormone therapy success, the levonorgestrel intrauterine device (89%, 8 out of 9 subjects) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10 mg/d (83%, 5 out of 6 subjects), and the transdermal patch (80%, 4 out of 5 subjects). All subjects using tranexamic acid as well as hormonal therapy had 100% achievement of menstrual suppression.

Conclusion: A high frequency of bleeding disorders was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. Although combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option.
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http://dx.doi.org/10.1016/j.jpag.2018.02.130DOI Listing
October 2018

Oroxylum indicum root bark extract prevents doxorubicin-induced cardiac damage by restoring redox balance.

J Ayurveda Integr Med 2019 Jul - Sep;10(3):159-165. Epub 2018 Feb 3.

Amala Cancer Research Centre (Recognized Research Centre of University of Calicut), Amala Nagar, Thrissur 680 555, Kerala, India. Electronic address:

Background: Oroxylum indicum Vent., a Dasamula plant used in Ayurveda possesses antioxidant properties.

Objectives: To evaluate the cardioprotective effect of 70% methanolic extract of O. indicum Vent. root bark (OIM) against doxorubicin induced cardiomyopathy in female Sprague Dawley rats.

Materials And Methods: Cardiotoxicity was induced by intra-peritoneal injection of doxorubicin 30 mg/kg body weight (b.w.) for 4 consecutive days after a ten-day pre-treatment of animals with OIM at 200 mg/kg b.w. and 400 mg/kg b.w (p.o.). Drug treatment continued up to day 14. Probucol, orally administered at a dose of 20 mg/kg b.w. served as standard. ECG was recorded. The animals were sacrificed on day 15 and comparative analysis of serum marker levels of creatine phosphokinase (CPK), lactate dehydrogenase (LDH), Serum Glutamate Oxaloacetate Transaminase (SGOT), Serum Glutamate Pyruvate Transaminase (SGPT), tissue antioxidant status based on Superoxide Dismutase (SOD), Glutathione Peroxidase (GPx), reduced Glutathione (GSH) and lipid peroxidation (LPO) was carried out. Histopathological examination was carried out using hematoxylin-eosin staining.

Results: ECG records of OIM treated animals showed normal pattern, in comparison to the control with ST depression and arrhythmia in cardiogram. Tissue antioxidant profile (SOD, GSH and GPx) was significantly (p < 0.01) elevated in the cardiac tissue of treated group in dose-dependent manner; lipid peroxidation level was found to decrease with treatment. Comparative analysis of serum markers - CPK, LDH, SGOT and SGPT - among untreated control, standard and extract treated groups revealed that OIM extract at 400 mg/kg b.w. dose significantly reduced the levels (p < 0.01). Histological analysis revealed normal myocardial architecture in OIM treated groups. HPTLC fingerprint of OIM revealed 8 bands and detected the presence of chrysin, apigenin and quercetin.

Conclusion: O. indicum root bark shows marked cardio-protective activity, possibly due to the presence of antioxidant compounds acting synergistically.
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http://dx.doi.org/10.1016/j.jaim.2017.06.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822150PMC
February 2018

Inhibition of Dimethylbenz(a)anthracene (DMBA) - Croton Oil-Induced Mouse Skin Tumorigenesis by Gmelina arborea with Potential Anti-Inflammatory Activity.

J Environ Pathol Toxicol Oncol 2016 ;35(3):263-272

Amala Cancer Research Centre (Recognized Centre of the University of Calicut, Kerala), Amala Nagar PO, Thrissur-680555, Kerala, India.

In traditional Indian medicine, the plant Gmelina arborea Linn. (GA) is described to have the ability to relieve edema. The present study evaluates the anticancer property of GA stem bark against 7,12-dimethylbenz(a) anthracene (DMBA)-croton oil-induced skin tumorigenesis along with the evaluation of anti-inflammatory activity. The observed inhibition of inflammation in carrageenan-induced (41.8%) and formalin-induced (34.07%) models may be due to inhibition of prostaglandins (PGs). Skin papilloma was induced by a single topical application of DMBA (470 nmol/200 µL acetone), followed by repeated application of croton oil (1% in 200 µL acetone). Low-concentration GA (GALC; 5% in 200 µL distilled water) and high-concentration GA (GAHC; 10% in 200 µL distilled water) were applied topically 30 min before croton oil application. The GALC and GAHC groups showed 85.7% and 57.14% tumor incidence, respectively. The number of papillomas per mouse was observed to be significantly (p ≤ 0.01) reduced in the treated groups. The onset of papilloma development was delayed considerably from 6 (control) to 12 wk (GAHC). Thus, results from the study give insights into the anticancer efficacy of Gmelina arborea, which may be due to prevention of inflammation-mediated tumor promotion by inhibiting PGs.
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http://dx.doi.org/10.1615/JEnvironPatholToxicolOncol.2016014572DOI Listing
February 2017

Physician Adherence to Centers for Disease Control and Prevention Guidelines for Sexually Active Adolescents in the Pediatric Emergency Setting.

Pediatr Emerg Care 2018 Nov;34(11):767-773

Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin.

Objectives: There is limited literature about physicians' adherence to 2010 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines specific to specimen collection testing methods in adolescent females in the emergency setting is limited. The objectives are to (1) determine physician adherence to CDC guidelines for specimen collection/testing for chlamydia and gonorrhea, (2) determine physician characteristics associated with guideline adherence, and (3) describe physicians' knowledge of expedited partner therapy (EPT) laws.

Methods: This is a cross-sectional, anonymous, Internet-based survey of physician members of the American Academy of Pediatrics Section of Emergency Medicine. Questions addressed practice patterns and knowledge through clinical scenarios of adolescent girls. Descriptive statistics are used to report frequency. Fisher exact and χ analyses are used to compare physician subgroups: gender, years in practice, practice setting, and geographical region.

Results: Overall, 257 physicians responded and 231 were analyzed; 62.4% females; 46.0% in practice for ≤ 7 years; 86.2% in academic medicine. Specimen collection/testing in an asymptomatic patient were consistent with guidelines for 85.6% of respondents, but decreased to 37.4% for a symptomatic patient. Guideline adherence was not different between physician subgroups. Only 30.4% of physicians reported state EPT law knowledge.

Conclusions: Adherence with the CDC guidelines for chlamydia/gonorrhea specimen collection/testing for adolescents in the emergency setting is inadequate, and EPT knowledge is poor. With increased emergency department use by adolescents, it is critical that physicians know and implement the current recommendations to improve adolescent health outcomes.
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http://dx.doi.org/10.1097/PEC.0000000000000873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378669PMC
November 2018

Radical scavenging and gastroprotective activity of methanolic extract of Gmelina arborea stem bark.

J Ayurveda Integr Med 2016 Apr-Jun;7(2):78-82. Epub 2016 Jul 20.

Department of Biochemistry, Amala Cancer Research Centre, Thrissur, Kerala, India. Electronic address:

Background: Gmelina arborea (GA) is widely used in traditional medicine for treating a number of ailments including gastrointestinal tract disorders.

Objective: To evaluate the gastroprotective effect of GA stem bark against ethanol-induced gastric ulcer in Wistar rats.

Materials And Methods: All animals were fasted for 36 h and received GA extract 250 and 500 mg/kg body weight (bw), 1 h before the administration of ethanol. The animals received ranitidine 50 mg/kg bw which served as the standard. The rats were sacrificed after 4 h. Then, the injuries to the gastric mucosa were estimated through gross evaluation of ulcer lesions and histology. The antioxidant parameters such as level of lipid peroxidation, superoxide dismutase (SOD), reduced glutathione (GSH), and glutathione peroxidase (GPx) in gastric tissue were also determined.

Results: GA treatment at a dose of 500 mg/kg bw offered 91.98% inhibition of ulcer formation, which is higher than that of ranitidine. The ethanol treatment extensively increased lipid peroxidation and it was significantly (P < 0.01) reduced in GA-treated group that eventually helped to prevent free radical accumulation. The GA enhanced the gastric mucosal antioxidant system, as indicated by a dose-dependent increase in the level/activities of GSH, GPx, and SOD. GA also attenuated the severity of histological signs of cell damage. Further, GA extract showed in-vitro 2,2-diphenyl-1-picrylhydrazyl radical scavenging activity with IC50 value of 124.39 μg/ml.

Conclusion: The results indicate that the gastroprotective effect of GA is probably related to its antioxidant activities that protect gastric mucosa against oxidative damage and antilipid peroxidative activity that maintain membrane integrity.
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http://dx.doi.org/10.1016/j.jaim.2016.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969311PMC
August 2016

A novel device to create consistent deep dermal burns in a porcine model.

Int J Burns Trauma 2016 1;6(2):26-9. Epub 2016 Jun 1.

Department of Paediatric Surgery, The Children's Hospital Burns Research Institute and Burns Unit, The Children's Hospital at WestmeadNew South Wales, Australia; Sydney Medical School, The University of SydneyNew South Wales, Australia.

We conducted this study to evaluate a novel device to create a consistent and reproducible deep partial thickness burn in a porcine model. A thermostatically controlled, heated aluminium disc device was fashioned by the Biomedical Department of our institution. Contact burns were made on the flank of two Great White pigs by applying the device heated to 92°C at intervals of 5, 10, 15 and 20 seconds to four separate test areas area of skin. Biopsies for histological analysis of burn depth were taken on day 0 at 10 minutes post burn and on day 8. Biopsies taken at day 0 revealed superficial to mid-dermal burns, with minimal dermal edema and necrosis. Those from day 8 showed mid to deep dermal edema and necrosis in all four test areas following a 20 second contact duration burn. The new contact burn device was able to create a consistent deep dermal burn after 20 seconds of contact. We anticipate that this new device could be used to investigate the development of hypertrophic scarring in a porcine model.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913230PMC
June 2016

Attenuation of DMBA/croton oil induced mouse skin papilloma by Apodytes dimidiata mediated by its antioxidant and antimutagenic potential.

Pharm Biol 2016 Sep 15;54(9):1564-74. Epub 2016 Feb 15.

a Department of Biochemistry , Amala Cancer Research Centre, Amala Nagar (Recognized Research Centre - University of Calicut) , Thrissur , Kerala , India.

Context Considering the role of cellular oxidative stress in mutations and subsequent transformation, phytochemicals with antioxidant potential has become a primary choice as chemopreventives. Apodytes dimidiata E. Mey. Ex. Arn (Icacinaceae), a widely used plant in Zulu traditional medicine, is reported to possess antioxidant activity. Objective To investigate the chemopreventive efficacy of methanol extract of A. dimidiata leaf (AMF). Materials and methods Antimutagenic potential of AMF (25, 50 and 75 μg/plate) was evaluated by the Ames test. The ability of AMF (100 and 250 mg/kg orally) on restoration of depleted antioxidant status by sodium fluoride (NaF) was analysed on BALB/c mice. 7,12-Dimethylbenz[a]anthracene/croton oil induced mouse skin papilloma model was studied up to 20 weeks to analyse the anticarcinogenic effect of AMF (1%, 3% and 5% topically, twice weekly for 6 weeks). Phytochemicals of AMF were characterized by GC-MS. Results AMF (75 μg/plate) reverted 4-nitro-o-phenylenediamine (NPDA) induced mutations in Salmonella typhimurium strains, TA 98, 100 and 102 by 74.8%, 72.5% and 69.3%, respectively. Against sodium azide, the percentage reversion was 80.4, 71.3 and 71.3. In mice, AMF (250 mg/kg for 4 days) increased the serum superoxide dismutase (SOD) and catalase activities by 48.71% and 30.3% against the NaF-induced drop. GSH level was improved by 48.59% with a concomitant decrease in TBARS (57.67%). The skin papilloma reduction was 79.32% for 5% AMF. Squalene, dodecanoic, tetradecanoic and hexadecanoic acids are the known antioxidant and chemopreventive molecules identified by GC-MS. Discussion and conclusion Antioxidant and antimutagenic activities of AMF might have contributed to its anticarcinogenic potential.
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http://dx.doi.org/10.3109/13880209.2015.1107747DOI Listing
September 2016

Screening for Chlamydia and Gonorrhea Cervicitis and Implications for Pregnancy Outcome. Are We Testing and Treating at the Right Time?

J Reprod Med 2015 Jul-Aug;60(7-8):301-8

Objective: To evaluate the effect of gonorrheal and chlamydial cervicitis (GCC) on the risk of preterm labor (PTL) and preterm premature rupture of membranes (PPROM).

Study Design: A large cross-sectional sample of patients (N = 1,120) was studied. Data on samples for GCC and pregnancy outcome were entered into a database from a retrospective chart review.

Results: There were 1,120 pregnancies with adequate data for analysis. Of those pregnancies 933 were unaffected by GCC, and 187 were affected. The rates of preterm delivery were 17.79% and 16.58% for GCC-negative and GCC-positive pregnancies, respectively. PPROM occurred in 3.97% and 2.67% of GCC-negative and GCC-positive pregnancies, respectively. PTL occurred in 8.25% and 8.02% of GCC-negative and GCC-positive pregnancies, respectively. No outcomes met statistical significance. When pregnancy outcomes were analyzed by trimester of infection, there was a higher risk of preterm delivery but not preterm labor with earlier infection. This did meet statistical significance. There was a trend towards lower rate of cesarean section in the infected group of patients, which did not meet statistical significance.

Conclusion: Maternal infection with gonorrhea and/or chlamydia is not associated with PPROM or PTL.
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November 2015

Vitamin D Deficiency among Adolescent Females with Polycystic Ovary Syndrome.

J Pediatr Adolesc Gynecol 2015 Oct 4;28(5):378-81. Epub 2014 Dec 4.

Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Study Objective: Studies have suggested that low vitamin D levels may play a role in the pathogenesis of polycystic ovary syndrome (PCOS). The aim of our study was to compare 25-hydroxyvitamin D [25(OH)D] levels in adolescent females with and without PCOS.

Design, Setting, And Participants: Retrospective chart review at a tertiary care medical center for female adolescents aged 12-21 years with serum 25(OH)D measurements within a 5-year period. Participants were categorized as having PCOS or as controls based on National Institutes of Health PCOS diagnostic criteria.

Main Outcome Measure: Exact logistic regression analysis was done to compare normal (≥30 ng/mL) vs low (<30 ng/mL) serum 25(OH)D levels in the PCOS and control groups.

Results: Two hundred ninety-nine charts were reviewed and 107 participants were included in the study. Of the included participants, 37 were in the PCOS group and 70 were in the control group, with a mean age of 15.2 years. In the PCOS group, 97.2% were obese and vitamin D deficiency was noted among 62.2% females. The mean serum 25(OH)D level was 18.4 and 21.6 ng/mL in PCOS and control groups, respectively. The difference in mean 25(OH)D levels between the 2 groups was not statistically significant (P > .05) when controlled for ethnicity, body mass index percentile, and season.

Conclusion: In our study, there was no statistically significant difference in mean 25(OH)D levels between PCOS and control groups. The majority of participants in PCOS group were obese. Further studies in adolescent females with PCOS and normal body mass index could be helpful in delineating the role of vitamin D in the pathogenesis of PCOS.
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http://dx.doi.org/10.1016/j.jpag.2014.11.004DOI Listing
October 2015

Prospective, randomised controlled trial comparing Versajet™ hydrosurgery and conventional debridement of partial thickness paediatric burns.

Burns 2015 Jun 25;41(4):700-7. Epub 2015 Feb 25.

The Children's Hospital at Westmead Burns Research Institute, The Children's Hospital at Westmead, Cnr Hawkesbury Rd and Hainsworth St, Westmead, NSW 2145, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.

Introduction: Conventional surgical debridement of burn wounds consists of tangential excision of eschar using a knife or dermabrasion until viable dermis or punctate bleeding occurs. The Versajet™ (Smith and Nephew, St. Petersburg, FL, USA) hydrosurgery system has also been advocated for burn wound debridement, with the suggestion that enhanced preservation of dermal tissue might reduce subsequent scarring.

Methods: A prospective randomised controlled trial was undertaken comparing Versajet™ to conventional debridement. After excluding those with facial burns, 61 children ≤16 years of age undergoing debridement and skin grafting for partial thickness burns were recruited. Adequacy of debridement was assessed by 2mm punch biopsies taken pre- and post-debridement. Surgical time, percentage graft take at day 10, time to healing, post-operative infection and scarring at 3 and 6 months were assessed.

Results: Thirty-one children underwent conventional debridement and 30 debridement using Versajet™. There was a significant difference in the amount of viable dermal preservation between the two groups (p=0.02), with more viable tissue lost in the conventional group (median 325 μm) versus the Versajet™ group (median 35 μm). There was no significant difference between graft take at day 10 (p=0.9), post-operative wound infection (p=0.5), duration of surgery (p=0.6) or time to healing after grafting (p=0.6). Despite better dermal preservation in the Versajet™ group, there was no significant difference between scarring at 3 or 6 months (p=1.0, 0.1).

Conclusions: These findings suggest that Versajet™ hydrosurgery appears a more precise method of burn wound debridement. Although dermal preservation may be a factor in reducing subsequent hypertrophic scarring, there were no significant differences found between scarring at 3 or 6 months after-injury.
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http://dx.doi.org/10.1016/j.burns.2015.02.001DOI Listing
June 2015

Use of biliary stent in laparoscopic common bile duct exploration.

Surg Endosc 2015 May 24;29(5):1094-8. Epub 2014 Sep 24.

Department of Surgery Darling Downs Health Service, Queensland Health, Toowoomba, QLD, Australia,

Introduction: It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy.

Methods And Procedures: The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study.

Results: The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group.

Conclusion: Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.
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http://dx.doi.org/10.1007/s00464-014-3797-yDOI Listing
May 2015

Pediatric burn wound impetigo after grafting.

J Burn Care Res 2015 Mar-Apr;36(2):e41-6

From the Burns Unit and The Children's Hospital at Westmead Burns Research Institute, Douglas Cohen Department of Paediatric Surgery, The Children's Hospital Westmead, Sydney Medical School, The University of Sydney, New South Wales, Australia.

Modern burn care techniques have reduced the risk of infection of the acute burn wound, resulting in more rapid healing and a lower incidence of graft loss. Secondary breakdown may still occur. The loss of epithelium in association with multifocal superficial abscesses and ulceration has been termed burns impetigo. This may result in considerable morbidity and require prolonged treatment. The events preceding development, the impact on the patient, and the ideal treatment appear unclear and poorly reported. In 5 years, between 2006 and 2011, 406 pediatric burns were treated with skin grafts, with 7% developing burns impetigo. Time to resolution ranged from 5 to 241 days: the mean time to complete healing was greatest with conservative management (96 days), followed by antibacterial dressings (37 days), oral antibiotics (36 days), topical steroids (16 days), and oral antibiotics in combination with topical steroids (13.5 days). Burns impetigo resulted in significant morbidity, requiring multiple visits to the treatment center and prolonged symptoms. Delay in diagnosis and treatment resulted in worse outcomes. Prompt consideration of burns impetigo should occur when postgraft patients present with suggestive clinical signs and treatment with oral antibiotics plus topical steroids should be considered.
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http://dx.doi.org/10.1097/BCR.0000000000000070DOI Listing
November 2015

Pediatric scalp burns: hair today, gone tomorrow?

J Burn Care Res 2015 Mar-Apr;36(2):e18-22

From the *Children's Hospital at Westmead Burns Research Institute and the †Burns Unit, Douglas Cohen Department of Paediatric Surgery, Sydney Medical School, The University of Sydney, New South Wales, Australia.

Scalp burns in the pediatric population appear relatively uncommon, with most reported cases occurring in adults secondary to electrical burns. We reviewed our experience with the management of these injuries in children. A retrospective review was conducted at our institution from March 2004 to July 2011. Scalp burns were defined as any burn crossing over the hairline into the scalp region. During the 7-year 4-month study, there were 107 scalp burns, representing 1.8% of the 6074 burns treated at our institution during that time. The cause was scald in 97, contact in 4, flame in 3, friction in 2, and chemical in 1. The majority (n = 93, 87%) appeared superficial to mid-dermal, with an average time to complete healing of 10.3 days. The remaining 14 cases (13%) were mid-dermal to full thickness, with an average time to complete healing of 50.8 days. Grafting was required in 12 cases (11%). The mean time to grafting was 4 weeks (range, 2 weeks to 2.5 months). The main complication of scalp burns was alopecia, which occurred in all grafted sites as well as in 4 patients treated conservatively. There were no other complications after grafting and no cases of graft loss. In our pediatric series, scalp burns were most commonly caused by scald injuries and were superficial to mid-dermal in depth. These generally healed rapidly but occasionally resulted in alopecia. The management of deep dermal and full-thickness scalp burns remains challenging in children, with the decision to graft often delayed.
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http://dx.doi.org/10.1097/BCR.0000000000000071DOI Listing
November 2015

The use of the trapdoor incision for access to thoracic inlet pathology in children.

J Pediatr Surg 2013 May;48(5):1147-51

Department of Paediatric Surgery, Our Lady's Children's Hospital Crumlin, Dublin, Ireland.

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.
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http://dx.doi.org/10.1016/j.jpedsurg.2013.03.061DOI Listing
May 2013

PCOS: perspectives from a pediatric endocrinologist and a pediatric gynecologist.

Curr Probl Pediatr Adolesc Health Care 2013 May-Jun;43(5):104-13

Department of Pediatrics, Section of Endocrinology & Diabetes, Medical College of Wisconsin, Milwaukee, WI, USA.

Polycystic ovary syndrome is the most common endocrinopathy recognized in women of childbearing age with a prevalence of 4-12%. The prevalence of the disorder in adolescent population is poorly defined. The pathogenesis as well as the management of this disorder is widely debated.
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http://dx.doi.org/10.1016/j.cppeds.2013.01.002DOI Listing
October 2013

The use of the Meek technique in conjunction with cultured epithelial autograft in the management of major paediatric burns.

Burns 2013 Jun 29;39(4):674-9. Epub 2012 Sep 29.

The Burns Unit and The Children's Hospital at Westmead Burns Research Institute, Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, NSW, Australia.

Background: The management of major paediatric burns remains challenging, in part due to limited donor sites. Skin graft expansion facilitates rapid closure of the burn wound, reducing the risk of sepsis. We reviewed our unit's experience with a combined modified Meek technique and cultured epithelial autograft (CEA).

Methods: A retrospective chart review over a seven year period from April 2004 to April 2011 was conducted of patients whose burns were treated with Meek and CEA.

Results: The Meek technique was combined with meshed split skin grafts and CEA to either donor, graft site or both in 7 cases. One case had Meek skin grafts alone with cultured cells applied to both donor and graft sites. There were two scald burns and five flame burns, with total body surface area ranging from 30% to 70%. Mean length of stay was 51 days (range 41-74 days). The average number of surgical procedures undergone to obtain good coverage was 3.3. There were small (1-3%) areas of breakdown in six cases which received regrafting. Two of these patients had confirmed wound infections. All patients had varying degrees of hypertrophic scarring (HTS) but remained well at follow up.

Conclusions: The Meek technique facilitates high expansion ratios, allowing for a greater area of skin coverage. Epithelialisation in the burn wound appeared to be enhanced by the application of CEA. The Meek technique in combination with CEA would appear a useful additional option in achieving wound closure in the severely burned paediatric patient.
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http://dx.doi.org/10.1016/j.burns.2012.09.009DOI Listing
June 2013

Friction burns in children: does laser Doppler imaging have a role?

J Burn Care Res 2012 Nov-Dec;33(6):736-40

Burns Unit and The Children's Hospital Burns Research Institute, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, New South Wales, Australia.

Laser Doppler imaging (LDI) has been increasingly used to predict pediatric burn wound outcome. A majority of these wounds are scald, contact, or flame burns. No study has specifically evaluated the use of LDI in pediatric friction burns. Our objective was to critically evaluate LDI assessment of pediatric friction burns to determine its predictive value with this mechanism of injury. We conducted a retrospective review of all LDI scans performed on pediatric friction burns during a 2-year period. We identified 36 patients with a mean age of 3.6 years (range, 19 months to 15 years). LDI accurately predicted burn wound outcome in 23 (64%) cases. In 13 cases, LDI did not correctly predict burn wound outcome. Eight were expected to heal within 14 days, but six of those eight took an average of 20.3 days to heal (range, 18-29 days), and the other two required skin grafting. Of the remaining five incorrect predictions, four were caused by an inability to correlate the flux scan with the clinical appearance of the burn, and one was thought to take more than 21 days to heal but healed within this period. Our data suggest that LDI appears to be a less reliable tool in predicting the outcome of friction burns when compared to other mechanisms of burn injury in children. This may reflect the physical differences in the mechanism of friction burns as opposed to other forms of thermal injury.
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http://dx.doi.org/10.1097/BCR.0b013e3182504469DOI Listing
May 2013

The importance of risk tolerance in maternal autonomy.

Am J Bioeth 2012 ;12(7):53-4

Medical College of Wisconsin, USA.

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http://dx.doi.org/10.1080/15265161.2012.680537DOI Listing
September 2012

Low-grade fibromyxoid sarcoma, a deceptively benign tumor in a 5-year-old child.

Pediatr Surg Int 2012 Feb 1;28(2):211-3. Epub 2011 Dec 1.

Department of Surgery, The Children's Hospital at Westmead, Sydney, Australia.

Low-grade fibromyxoid sarcoma (LGFMS) is very uncommon in the pediatric population with only 20% of reported cases under the age of 18. The youngest reported case to date has been in a 4-year-old child. Lesions are usually slow growing and asymptomatic, and locations described in children have included paravertebral, thigh and intrathoracic. Although benign in appearance, these lesions can behave aggressively, with local recurrence and distant metastases primarily to lungs. These lesions can be resistant to the usual chemotherapy and radiotherapy with surgical resection being the treatment of choice. We report a case of a 5-year-old boy who presented with a mass in the left buttock.
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http://dx.doi.org/10.1007/s00383-011-3024-zDOI Listing
February 2012

Laparoscopic exploration of the common bile duct to relieve choledocholithiasis in children.

Pediatr Surg Int 2011 May;27(5):537-40

Department of Paediatric Surgery, Sydney Childrens' Hospitals Network, Westmead Campus, Sydney, NSW, 2145, Australia.

Purpose: The optimal method of managing paediatric choledocholithiasis is controversial. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are effective in adults; however, the long-term outcome in the paediatric population is unknown. We report our experience with laparoscopic common bile duct (CBD) exploration to relieve choledocholithiasis in children and propose a management algorithm.

Methods: A retrospective chart review of 124 children, who underwent cholecystectomy over 5 years was conducted. Data collected included age at onset, duration of symptoms, length of stay, method of relieving choledocholithiasis and postoperative outcome.

Results: Mean age was 12.5 years (range 10-14 years). 102 cholecystectomies were performed laparoscopically. Following intraoperative cholangiogram (IOC), choledocholithiasis was identified in eight patients. In three cases, the CBD was flushed with normal saline via a 5F ureteral catheter successfully relieving the obstruction. In three cases, a Dormia basket was used to break down the stone. Two cases required postoperative ERCP and sphincterotomy to successfully extract the stones. All children were symptom-free at follow-up with no complications reported to date.

Conclusion: Laparoscopic CBD exploration with Dormia basket or saline flushes to relieve choledocholithiasis is a safe and effective alternative in children. If unsuccessful, ERCP and sphincterotomy can be performed in centres with adequate resources and expertise.
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http://dx.doi.org/10.1007/s00383-010-2826-8DOI Listing
May 2011

Hyperprolactinemia-related adverse events associated with antipsychotic treatment in children and adolescents.

J Adolesc Health 2009 Jul 9;45(1):70-6. Epub 2009 Mar 9.

Department of Neuropsychiatry, University of South Carolina School of Medicine, 3555 Harden Street Ext., CEB 301, Columbia, SC 29203, USA.

Purpose: To characterize factors related to the development of hyperprolactinemia and the ensuing reproductive/sexual adverse events in children and adolescents treated with antipsychotic and other psychotropic agents, and the additional risk posed for those with comorbid obesity, metabolic, or endocrine disorders.

Methods: A retrospective cohort design evaluating medical and pharmacy claims from South Carolina's Medicaid program was used to compare incidence rates for sexual/reproductive adverse events in 4140 children and adolescents who were newly prescribed one of six atypical or two conventional antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications, January 1998 to December 2005. Logistic and Cox Proportional Hazards regression and Kaplan-Meier survival analysis were performed.

Results: The treated cohort was not significantly more likely to evince hyperprolactinemia-related disorders than the control sample, but females and adolescents 13 and older were. Incident reproductive/sexual conditions were more likely for females (odds ratio [OR] = 9.52; confidence interval [CI] = 7.63-11.90), adolescents (OR = 3.91; CI = 3.25-4.70), those also taking selective serotonin reuptake inhibitors (SSRIs) (OR = 2.04; CI = 1.56-2.37) or valproic acid derivatives (OR = 1.29; CI = 1.03-1.64), and those with comorbid obesity/weight gain (OR = 1.92; CI = 1.56-2.37), metabolic (OR = 1.41; CI = 1.12-1.78), or endocrine disorders (OR = 2.76; CI = 1.98-3.84).

Conclusion: In this treated cohort, female adolescents exposed to SSRIs or valproic acid derivatives and those with comorbid obesity, metabolic, or endocrine disorders while taking antipsychotics were at higher risk of developing hyperprolactinemia and ensuing sexual/reproductive adverse events.
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http://dx.doi.org/10.1016/j.jadohealth.2008.11.010DOI Listing
July 2009

Cervical cytology screening and management of abnormal cytology in adolescents.

J S C Med Assoc 2009 Feb;105(1):16-9

The consensus guidelines recognize adolescents as a special group and allow for more conservative follow- up of abnormal cytology and histology. The guidelines recognize the role of high rates of HPV infection and reinfection in teens, along with high rates of clearance of HPV and low rates of invasive cervical cancer. Risks of treatment are balanced with risk for disease progression. The cervical cancer vaccine is now recommended for teens. The approved vaccine protects against HPV related disease caused by four subtypes of HPV 6, 11, 16, and 18. The Food and Drug Administration has approved the vaccine as routine for 11- and 12-year-old girls. The vaccine is most effective prior to HPV exposure or before the sexual debut. In South Carolina only 4.8% of high school girls indicate having sexual intercourse before age 13. Vaccination provides an opportunity to review risky behaviors with adolescent patients and to encourage healthy, safe lifestyles. Vaccination is not protective for sexually transmitted infections and this can be emphasized at vaccination visits as well. The importance of cancer screening can also be reviewed with patients at vaccination visits.
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February 2009

Prepubertal Skene's abscess.

J Pediatr Adolesc Gynecol 2009 Feb;22(1):e21-2

University of South Carolina, Columbia, South Carolina 29203, USA.

Background: Skene's glands are believed to be homologues of the prostate gland derived from the urogenital sinus.(1) Complications of Skene's glands occur most often in the third and fourth decades and are rarely seen in premenarchal females.

Case: A 3-year-old presented to her pediatrician with a 9-day complaint of vulvar pain. Both pediatric and gynecologic office examination revealed an enlarged right labium majus and an erythematous area adjacent to the urethra. Examination under anesthesia revealed a Skene's gland abscess that was treated with incision and drainage. The patient experienced complete resolution of symptoms.

Conclusion: A Skene's gland abscess is rare among premenarchal girls. An abscess presenting in a patient complaining of pain can be successfully managed with incision and drainage.
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http://dx.doi.org/10.1016/j.jpag.2007.11.004DOI Listing
February 2009

The effect of ambulation on vaginal distribution of miconazole nitrate (1200 mg).

J Womens Health (Larchmt) 2007 Jun;16(5):703-6

Reproductive Research Unit, Penn Fertility Care, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: To evaluate the effect activity has on the vaginal distribution of a 1200 mg miconazole nitrate gelatin encapsulated insert, an antifungal agent commonly used to treat vaginal vulvocandidiasis.

Method: Nine subjects underwent two sessions of serial magnetic resonance imaging after insertion of the insert. One session required that the subjects ambulate between images; the other session required the subjects remain supine between images. Vaginal distribution of the insert was quantified by calculating surface contact and linear distance in every image. Comparison of spread was then done between images taken in active subjects and images taken in resting subjects. Time until capsule dissolution was also compared between the two groups.

Results: No statistically significant difference was seen in spread of insert between the active and resting group. Activity also had no significant effect on capsule dissolution.

Conclusion: Activity does not appear to hinder the spread of the insert, suggesting that this medication can be used daytime or nighttime.
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http://dx.doi.org/10.1089/jwh.2006.0163DOI Listing
June 2007

Risk factors for ectopic pregnancy: a comparison between adults and adolescent women.

J Pediatr Adolesc Gynecol 2007 Jun;20(3):181-5

Penn Fertility Care, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.

Purpose: To compare the prevalence of classical risk factors and presenting signs and symptoms between adolescents and adults with ectopic pregnancy (EP).

Procedure: A database containing information regarding presentation symptoms, past medical history, and ultimate pregnancy outcomes of patients presenting to the Emergency Department during early pregnancy is maintained in our institution. Data were extracted and analyzed for all patients ultimately diagnosed with EP. Patients were separated into adult (> or =20 years of age) and adolescent groups (<20 years of age). Adjusted comparisons were made between these two groups regarding pain, vaginal bleeding, current and past pelvic infections, prior pregnancy history, and prior surgery using Pearson's chi-square, t test, and multivariable models.

Results: The incidence of EP was lower in the adolescent group versus the adult group (9.7% versus 21.7%). Classical risk factors such as prior EP (P < 0.01), and prior pelvic surgery (P < 0.01) were significantly more likely to be associated with adults than adolescents with EP. Adolescent patients were significantly more likely to present with abdominal pain (P = 0.045) and current gonorrhea and/or chlamydia (gc/ct) infection (P < 0.01).

Conclusions: This preliminary study suggests that different risk factors may be associated with EP in adolescents compared to adults.
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http://dx.doi.org/10.1016/j.jpag.2007.01.007DOI Listing
June 2007

Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review.

Fertil Steril 2007 Mar 14;87(3):481-4. Epub 2006 Dec 14.

Penn Fertility Care, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.

Objective: Successful medical management of an ectopic pregnancy is inversely associated with initial hCG level. The purpose of this publication is to assess whether there is a level of hCG above which failure rate substantially increases.

Design: A systematic review and summary analysis was performed, including studies reporting methotrexate treatment outcomes as stratified by various hCG ranges.

Setting: Academic medical center.

Patient(s): Review of published information regarding patients treated with methotrexate.

Intervention(s): None.

Main Outcome Measure(s): Success and failure rate of medical management.

Result(s): Five observational studies, including 503 women, were found that reported successes in using single-dose methotrexate stratified by initial hCG concentration. Failure rates increase with increasing hCG levels. A substantial and statistically significant increase in failure rates is seen when comparing patients who have initial hCG levels of >5,000 mIU/mL with those who have initial levels of <5,000 mIU/mL (odds ratio: 5.45; 95% confidence interval: 3.04, 9.78). The failure rate for women who had an initial concentration between 5,000 and 9,999 mIU/mL was significantly higher than that for those who had initial levels between 2,000 and 4,999 mIU/mL (odds ratio: 3.76; 95% confidence interval: 1.16, 12.33).

Conclusion(s): Results support a substantial increase in failure of medical management with single-dose methotrexate when the initial hCG is above 5,000 mIU/mL. Methotrexate should be used with caution in patients with ectopic pregnancy who present with hCG levels above this level.
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http://dx.doi.org/10.1016/j.fertnstert.2006.10.007DOI Listing
March 2007