Ocular and orbital tumors in childhood

Pediatric tumors of the eye and orbit can be benign or malignant as well as congenital or acquired and are usually distinctively different than those seen in adults. Although most of these neoplasms are benign (eg, dermoid cyst, chalazion, molluscum), their location near and within a vital organ can result in serious dermatologic and ophthalmologic sequelae. Lesions discussed include vascular lesions, retinoblastomas (the most common primary pediatric intraocular malignancy), rhabdomyosarcoma (the most common primary pediatric orbital malignancy), Langerhans cell histiocytosis, and metastatic lesions to the orbit (neuroblastoma, Ewing sarcoma). Although cysts and ocular melanoma can occur within the pediatric population, these conditions are covered in other contributions in this issue of Clinics in Dermatology.

Perceptions of skincare ingredients and product labels in pediatric eczema care

Educating pediatric eczema patients and caregivers on appropriate product selection and avoidance of common irritants or allergens is a crucial aspect of eczema management. This study surveyed 80 pediatric caregivers in an academic pediatric dermatology clinic to assess influential factors in caregivers' selection of pediatric eczema-care products and identify ways to improve patient counseling on appropriate product selection and avoidance of common irritants or allergens. Caregivers frequently reported positive perceptions of commonly recommended ingredients for eczema but had inconsistent perceptions of fragrant plant oils and extracts, regardless of previous counseling on fragrance avoidance. These findings demonstrate uncertainty and misperceptions perpetuated by product labeling and a need for improved counseling strategies for avoiding fragrance and excessive product costs.

Oral candidiasis and seborrheic dermatitis in an 8-year-old female with a heterozygous variant of the IL-17RC gene

An 8-year-old female with chronic oral candidiasis and severe seborrheic dermatitis was found to have a heterozygous mutation (p.R14X c.40 C>T) of the IL-17RC gene, which was predicted to possibly represent a new pathogenic variant via truncation or nonsense-mediated mRNA decay. Given previously reported IL-17RC-related disorders are autosomal recessive, we would expect an affected individual to have two mutated alleles whereas our patient was heterozygous. Given the overlapping clinical picture, this variant could be responsible for altered immunity against both Candida and Malassezia species. This is the first report to our knowledge of chronic oral candidiasis and severe seborrheic dermatitis in a patient with a heterozygous variant (p.R14X c.40 C>T) for the IL-17RC gene.

Child maltreatment-related children's emergency department visits before and during the COVID-19 pandemic in Connecticut

BACKGROUND

Previous studies of national emergency department (ED) data demonstrate a decrease in visits coded for physical abuse during the pandemic period. However, no study to date has examined the incidence of multiple child maltreatment types (physical abuse, sexual abuse, and neglect), within a single state while considering state-specific closure policies. Furthermore, no similar study has utilized detailed chart review to identify cases, nor compared hospital data to Child Protective Services (CPS) reports.

OBJECTIVE

To determine the incidence of child maltreatment-related ED visits before and during the COVID-19 pandemic, including characterizing the type of maltreatment, severity, and CPS reporting.

PARTICIPANTS AND SETTING

Children younger than 18 years old at two tertiary-care, academic children's hospitals in X state.

METHODS

Maltreatment-related ED visits were identified by ICD-10-CM codes and keywords in chief concerns and provider notes. We conducted a cross-sectional retrospective review of ED visits and child abuse consultations during the pre-COVID (1/1/2019-3/15/2020) and COVID (3/16/2020-8/31/2020) periods, as well as state-level CPS reports for suspected maltreatment.

RESULTS

Maltreatment-related ED visits decreased from 15.7/week in the matched pre-COVID period (n = 380 total) to 12.3/week (n = 296 total) in the COVID period (P < .01). However, ED visits (P < .05) and CPS reports (P < .001) for child neglect increased during this period. Provider notes identified 62.4% of child maltreatment ED visits, while ICD-10 codes identified only-CM captured 46.8%.

CONCLUSION

ED visits for physical and sexual abuse declined, but neglect cases increased during the COVID-19 pandemic in X state.

Cutaneous Manifestations of Child Abuse & Neglect: Part I

Child abuse and neglect remains a significant cause of morbidity and mortality in children. Dermatologists may not fully conceptualize their crucial role in the evaluation of child abuse and neglect as both mandated reporters and experts in skin pathology. This CME summarizes the current information on cutaneous signs and clinical simulants of abuse for dermatologists so that dermatologists gain more insight into the skin examination for child abuse and neglect, develop confidence in their ability to distinguish dermatologic signs of accidental versus inflicted trauma, and more frequently consider abuse and neglect in their differential diagnosis.

Cutaneous Mimics of Child Abuse & Neglect: Part II

Given that some cutaneous mimics of child abuse result from rare disease, they may be more prone to misdiagnosis. For possible child abuse cases in which diagnosis remains uncertain at time of initial dermatologic evaluation, it is important that dermatologists are prepared to distinguish true dermatologic conditions in cases of ambiguous skin findings. Additionally, this review will aid clinicians in recognizing the possibility of concurrent true dermatologic disease and skin findings related to abuse with the acknowledgement that they are not mutually exclusive. Proper recognition of mimics of abuse may prevent unnecessary stress and child protective service investigation.

Nutrition and Water

Water has numerous functions necessary for survival including cellular homeostasis, solvent properties for dissolving ions and solutes, thermoregulation, and transport of waste and nutrients. Despite the established beneficial role of water in skin physiology, the optimal methods for skin hydration and requirements for daily water consumption remain elusive. This review summarizes the cellular and molecular biology of skin hydration, the debate and current recommendations of daily water requirements, and the latest research on interventions to improve skin hydration by both internal and external means of water exposure. We also explore the chemical properties of water, such as the concept of water "hardness" and environmental pollutants, and their impact on skin physiology.

Electronic Cigarettes Associated With Incident and Polysubstance Use Among Youth

PURPOSE

Electronic cigarette (e-cigarette) use has increased exponentially among the youth in the United States and may increase the incidence of substance use.

METHODS

Youth participants (12-17 years) were surveyed through the Population Assessment of Tobacco and Health study over a three-year time period. Youth with any baseline substance use or diagnosis of an attention deficit disorder were excluded from the analysis. Multivariable logistic regressions were used to assess the association between e-cigarette use at Wave 1 and incident substance use (marijuana, painkillers, sedatives, or tranquilizers and Ritalin/Adderall) and polysubstance use at Wave 2 or 3, and marijuana use in the electronic nicotine device at Wave 3.

RESULTS

Baseline ever e-cigarette users who had no history of marijuana, nonprescribed drugs and illicit substance use in Wave 1 had increased odds of reporting incident use of marijuana (odds ratio 2.59, 95% confidence interval: 1.90-3.52), nonprescribed Ritalin/Adderall use (1.89, 1.09-3.28), or polysubstance use (2.09, 1.43-3.05) in Wave 2 or 3 compared to never e-cigarette users. They were also more likely to report use of marijuana in the electronic nicotine product (2.26, 1.56-3.27) in Wave 3 compared to never e-cigarette users. There was no statistically significant association between baseline e-cigarette use and incident use of painkillers, sedatives, or tranquilizers in Wave 2 or 3 (1.21, .79-1.87).

CONCLUSIONS

E-cigarette use is associated with incident use of marijuana, marijuana in electronic nicotine devices, Ritalin/Adderall, and polysubstance use but not painkillers, sedatives, or tranquilizers. Results indicate that e-cigarettes are associated with subsequent additional risky health behaviors in youth.

A state-wide analysis of pediatric scald burns by tap water, 2016-2018

INTRODUCTION

Unsafe tap water temperatures (>120 °F) are a risk factor for pediatric burns, which may disproportionally impact low-income, urban communities. We sought to estimate the incidence and demographic characteristics of tap water burns and their association with housing characteristics.

METHODS

We performed a secondary data analysis to summarize emergency department discharge records from 2016 to 2018 involving children <18 years with an ICD-10-CM code for tap water burn (X11), and town-level housing data from the American Community Survey. Unpaired student's t-test and spearman's correlation analysis were performed for comparative analyses.

RESULTS

A total of 146 tap water burn visits were identified, representing an incidence of 2 per 10,000 ED visits. The majority of cases were male, non-Hispanic White, of public insurance type, and from an urban CT town. The median age was 3 years, with 58% of cases <5 years. Towns with at least one tap water burn had a significantly higher average percentage of multi-family unit and renter housing as compared to towns with no tap water burns (p < 0.0001).

CONCLUSIONS

Our results identified a significant number of tap water burns in children. Primary prevention efforts targeting education or regulation of water temperatures may work to reduce burns in underserved areas.

Child maltreatment surveillance following the ICD-10-CM transition, 2016-2018

BACKGROUND

Child maltreatment is poorly documented in clinical data. The International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) represents the first time that confirmed and suspected child maltreatment can be distinguished in medical coding. The utility of this distinction in practice remains unknown. This study aims to evaluate the application of these codes by patient demographic characteristics and injury type.

METHODS

We conducted secondary data analysis of emergency department (ED) discharge records of children under 18 years with an ICD-10-CM code for confirmed (T74) or suspected (T76) child maltreatment. Child age, sex, race/ethnicity, insurance status and co-occurring injuries (S00-T88) were compared by maltreatment type (confirmed or suspected).

RESULTS

From 2016 to 2018, child maltreatment was documented in 1650 unique ED visits, or 21.7 per 10 000 child ED visits. Suspected maltreatment was documented most frequently (58%). Half of all maltreatment-related visits involved sexual abuse, most often in females and individuals of non-Hispanic white race. Physical abuse was coded in 36% of visits; injuries to the head were predominant. Non-Hispanic black children were more frequently documented with confirmed physical abuse than suspected (38.7% vs 23.7%, p<0.01). The rate of co-occurring injuries documented with confirmed and suspected maltreatment differed by 30% (9.2 vs 12.5 per 10 000 ED visits, respectively).

CONCLUSIONS

The ability to discriminate confirmed and suspected maltreatment may help mitigate clinical barriers to maltreatment surveillance associated with delayed diagnosis and subsequent intervention. Racial disparities in suspected and confirmed cases were identified which may indicate biased diagnostic behaviours in the ED.

Child Sexual Abuse identified in Emergency Departments Using ICD-9-CM, 2011 to 2014

BACKGROUND

Child sexual abuse (CSA) is poorly identified due to its hidden nature and difficulty surrounding disclosure. Surveillance using emergency department (ED) data may identify victims and provide information on their demographic profile.

OBJECTIVES

Study aims were to calculate the prevalence of visits assigned an explicit or suggestive medical diagnosis code (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for CSA and compare the demographic profile of ED visits by coding type.

METHODS

This study examined ED data for children < 10 years of age in Connecticut from 2011 to 2014. Cases involving CSA were identified using explicit and suggestive ICD-9-CM codes and age qualifiers previously established in the literature, and compared across visit characteristics (age, race/ethnicity, sex, and primary insurance payer, and town group).

RESULTS

ICD-9-CM codes for explicit CSA were identified in 110 ED visits, or 1.7 per 10,000 total ED visits. Inclusion of ICD-9-CM codes for suggestive CSA identified an additional 630 visits (9.7 per 10,000 visits). Suggestive codes identified proportionally more visits of younger (50% vs. 38%) and male (35% vs. 22%) children, compared with the explicit code (p < 0.05).

CONCLUSIONS

This study demonstrates one method for identifying CSA cases, which has the potential to increase surveillance of victims in the ED. Results imply that explicit codes alone may overlook most cases, whereas use of suggestive codes may identify additional cases, and proportionally more young and male victims. As the health consequences of CSA are severe, innovative forms of surveillance must be explored to detect a higher number of cases and improve the clinical care of patients.

Stroke sensitivity in the aged: sex chromosome complement vs. gonadal hormones

Stroke is a sexually dimorphic disease. Elderly women not only have higher stroke incidence than age-matched men, but also have poorer recovery and higher morbidity and mortality after stroke. In older, post-menopausal women, gonadal hormone levels are similar to that of men. This suggests that tissue damage and functional outcomes are influenced by biologic sex (XX vs. XY) rather than the hormonal milieu at older ages. We employed the Four Core Genotype (FCG) mouse model to study the contribution of sex chromosome complement and gonadal hormones to stroke sensitivity in aged mice in which the testis determining gene (Sry) is removed from the Y chromosome, allowing for the generation of XX males and XY females. XXF, XXM, XYF, XYM and XYwt aged mice were subjected to middle cerebral artery occlusion (MCAO). XXF and XXM mice had significantly larger infarct volumes than XYF and XYM cohorts respectively. There was no significant difference in hormone levels among aged FCG mice. XXF/XXM mice also had more robust microglial activation and higher serum levels of pro-inflammatory cytokines than XYF/XYM cohort respectively. We concluded that the sex chromosome complement contributes to ischemic sensitivity in aged animals and leads to sex differences in innate immune responses.

Abstract T P324: Sex Differences in Ischemic Outcomes and Inflammatory Responses in Neonatal Stroke

Background and Purpose: Neonatal arterial ischemic stroke (NAIS) is an important cause of motor and cognitive impairment in children. Clinically, male infants are more vulnerable to ischemic insult and suffer more long-term deficits than female infants though the mechanisms remain elusive. Inflammatory processes are fundamental in the pathophysiology of ischemia as microglial activation initiates the inflammatory response after ischemia. Recent studies report a sexual dimorphism in microglia numbers and expression of activation markers in neonatal brains under normal conditions. How these basal sex differences in microglia affect NAIS remains largely unexplored. This study investigated sex differences in stroke phenotypes and inflammation triggered by NAIS. We hypothesize that ischemia induces sex-specific tissue injury in male and female neonates, which is related to differences in microglial activation and inflammatory responses.

Methods: Male and female C57BL6 mice were subjected to 60-minute Rice-Vanucci Modeling at post-natal day 10 (P10) to induce NAIS. Stroke outcomes were measured at 24 hours, 72 hours and 7 days after stroke. Microglial activation and inflammatory responses were evaluated by flow cytometry, immunohistochemistry, and multiplex cytokine analysis.

Results: At 24 hours no difference in infarct volumes (total infarct: male vs. female 46.6±7.2% vs. 43.2±9.3%, n=6/gp) and in Iba-1 staining of the ischemic brain were seen between male and female neonates. However, at 72 hours female neonates exhibited significantly smaller infarct size and improved behavior outcomes compared to males (total infarct: male vs. female 43.1±9.9% vs. 27.1±8.8%, n=6/gp, p <.05). Male animals demonstrated increased microglial activation and up-regulated inflammatory response compared to females at 72 hours. This male-specific phenotype was also seen at 7 days after injury. There was no difference in hormone levels at any of the three time points after stroke.

Conclusions: Acute ischemia leads to an equivalent primary brain injury in male and female P10 mice. However, infarct damage worsens in males at sub-acute time points vs. females, as does the immune response. This sex difference independent of hormone levels exists in NAIS.

Abstract W MP79: The Sex Chromosome Complement Contributes to Ischemic Stroke Sensitivity and Inflammatory Responses in Aged FCG Mice

Introduction: Aging is the most important non-modifiable risk factor for ischemic stroke; modeling stroke in aged animals is of clinical relevance and translational value. Stroke is a sexually dimorphic disease. Elderly women not only have higher stroke incidence than age-matched men, but also have poorer recovery, higher morbidity and mortality once a stroke occurs. Much of this has been attributed to the loss of estrogen with menopause. However, stroke incidence does not begin to climb until well after natural menopause, suggesting there are hormone independent effects on ischemic sensitivity. As hormone levels are relatively equivalent between sexes at the age post-menopausal, tissue damage and functional outcomes must be influenced by biologic sex (XX vs. XY) in addition to the hormonal milieu.

Hypothesis: We hypothesized that sex differences in ischemic stroke in aged brains are shaped by the sex chromosome complement.

Methods: The Four Core Genotype (FCG) mouse model was utilized to dissociate the effects of sex chromosome compliment from hormone exposure on ischemic sensitivity. XXF, XXM, XYF, and XYM aged mice (18-20 months) were subjected to 90-minute middle cerebral artery occlusion (MCAO). Stroke outcomes were examined at 24h and 7d of stroke. Inflammatory responses were also evaluated by flow cytometry, immunohistochemistry, and multiplex cytokine analysis.

Results: At 24h and 7d of stroke, more microglial activation and higher levels of pro-inflammatory cytokines (IL-1β and IL-6) were seen in XXF and XXM than in XYF and XYM mice respectively. Accordingly, XXF and XXM mice had significantly larger infarct volumes than XYF and XYM cohorts respectively (XXF vs.XYF: 43.26 ± 5.63% vs. 24.22 ± 3.48%; XXM vs. XYM: 50.44 ± 6.11% vs. 26.24 ± 3.91%; P <0.05, n=7~9/group) at 7d of stroke. There was no significant difference in hormone levels in aged FCG mice. Although no significant difference in neurological deficit scores (NDS) were seen between any two genotypes 24 hours after stroke, XXF and XXM mice exhibited worse NDS than XYF and XYM cohorts respectively at 7 d of stroke.

Conclusions: The sex chromosome complement contributes to ischemic sensitivity in aged animals, which is likely mediated in part by innate immune responses.