IMPORTANCE Child maltreatment adversely affects health and development, but evidence is needed regarding whether and how Child Protective Services (CPS) interventions may mitigate risks.OBJECTIVE To assess whether different forms of CPS intervention are associated with sexual and reproductive health outcomes among female adolescents investigated by CPS for suspected exposure to maltreatment during childhood. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used linked, longitudinal, statewide administrative data from Wisconsin, including medical assistance and CPS records, to examine the rates and correlates of sexual and reproductive health outcomes (sexual transmitted infections, pregnancies, births, and high-risk sexual behavior) among 9392 female adolescents tracked from age 13 through 17 years who were investigated by CPS for suspected exposure to maltreatment prior to their 13th birthday. The study assesses how these outcomes were associated with types and frequency of CPS involvement and intervention and with adolescent and family demographic characteristics. Participants were female adolescents born from 2000 through 2002 who were investigated by Wisconsin CPS for suspected exposure to maltreatment before 13 years of age and who were covered by medical assistance at least 85% of the time from 13 to 17 years of age.EXPOSURES Varying levels and intensities of CPS interventions, ranging from a single investigation to adoption from foster care.MAIN OUTCOMES AND MEASURES Dependent variables were pregnancy, birth, sexually transmitted infection, and an aggregate measure of sexual health concerns from 13 to 17 years of age. Primary explanatory variables were the intensity of CPS intervention (investigation only, in-home services, and foster care) and frequency of maltreatment concerns (number of investigations, continued involvement during adolescence). Logistic regression was used to assess the association of CPS measures with differences in sexual health outcomes. Data were analyzed from March 1 to October 12, 2021.RESULTS This cohort study included 9392 female adolescents, among whom 3156 (33.6%) were born in 2000, 3064 (32.6%) in 2001, and 3173 (33.8%) in 2002; 2501 adolescents [26.6%] were Black, 1568 [16.7%] were Hispanic, 1024 [10.9%] were multiracial, 4024 [42.8%] were White, and 275 [2.9%] were listed as other [which included American Indian, Asian or Pacific Islander, or unknown race or ethnicity]). By 18 years of age, sizable proportions of maltreated female adolescents had at least 1 concerning sexual health outcome (23.5%), including diagnoses of gonorrhea, chlamydia, or trichomoniasis (8.4%), pregnancy (11.2%), and parenthood (6.1%). Compared with CPS investigation without formal intervention, foster care was associated with lower odds of pregnancy (adjusted odds ratio, 0.82; 95% C, 0.69-0.98) and live birth (adjusted odds ratio, 0.78; 95% CI, 0.61-0.99). Recurrent and ongoing CPS involvement was associated with adverse sexual health outcomes.CONCLUSIONS AND RELEVANCE This cohort study found t...

A 77-year-old male with a history of persistent atrial fibrillation on warfarin developed an abdominal hematoma when his INR was supratherapeutic, so he was evaluated for WATCHMAN (Boston Scientific Corporation, Marlborough, MA) left atrial appendage occlusion. Transesophageal echocardiography (TEE) showed an adequately sized left atrial appendage so a 27mm WATCHMAN device was deployed. Angiogram showed the device in good position and TEE showed no peri-device leak or pericardial effusion. He was placed on a continuous heparin infusion which was maintained in the therapeutic range based on anti-Xa assay. The following morning, he was confused, clammy, and short of breath. Shortly thereafter the patient went into cardiac arrest. During arrest it was noted that the patient had a 4g drop in hemoglobin and intraarrest bedside ultrasound revealed a complex left pleural effusion, so he was transfused with protamine sulfate, vitamin K, fresh frozen plasma, packed red blood cells, and incompatible platelets. Return of spontaneous circulation was achieved after 16 minutes. Post-arrest a CT angiogram of the chest revealed a large left pleural effusion without evidence of perforation of any large arteries. Transthoracic echocardiogram showed no evidence of pericardial effusion. A left chest tube was placed with drainage of 2200 cc of frank blood in the first 12 hours. Endoscopy showed a superficial ulcer of the mid-esophagus but no evidence of esophageal perforation or tear. The patient was stabilized but ultimately had poor neurologic recovery due to anoxic brain injury and palliatively extubated and discharged home to family on comfort measures.DISCUSSION: Left atrial appendage closure with a WATCHMAN device has similar bleeding rates compared to warfarin alone, with a majority of major bleeding events occurring in the periprocedural period [2]. Although periprocedural bleeding after device implantation is not uncommon, hemothorax is a very rare complication occurring in only 0.1% of cases [1]. In this case rupture of the left atrial appendage or other perforation of cardiac structures was ruled out by the absence of a pericardial effusion, as well as bleeding from esophageal rupture after TEE. It is unclear whether dissections or perforations of smaller arterial or venous structures lead to the hemothorax or whether it was a spontaneous event related to heparin infusion. CONCLUSIONS:Hemothorax is a rare bleeding complication of WATCHMAN device implantation but needs to be considered as a potential major bleeding event after device deployment.

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Abdominal compartment syndrome (ACS) is defined as intra-abdominal hypertension with sustained increased intra-abdominal pressure causing new organ dysfunction [1]. Most commonly associated with trauma, burns, or liver transplantation, but in select cases ACS can be associated with intra-abdominal masses [2,3]. Definitive treatment is surgical decompression [2]. CASE PRESENTATION: A 51 year-old female presented to the ED via EMS for weakness and hypoglycemia. The patient stated that her symptoms developed earlier that day. Only past medical history was type 2 diabetes. Physical exam revealed dry mucous membranes, decreased breath sounds bilaterally, and a markedly distended abdomen firm to palpation. Reportedly, the abdominal distention had been present and worsening for >1 year. Initial labs: Na+ 129 mEq/L, BUN 29 mg/dL, Cr 1.5 mg/dL, platelet count 628,000 cells/mL, glucose 38 mg/dL. CT abdomen/pelvis showed an ovarian/uterine mass measuring approximately 40 cm x 34 cm x 40 cm. CEA, CA 125 and CA19-9 were 17.4 ng/mL, 22 U/mL and 1396 U/mL, respectively. She was administered D50 and started on a D5 IV infusion. Overnight, she began to experience worsening respiratory distress requiring BiPap. She ultimately required intubation and was transferred to ICU. Bronchoscopy was performed at bedside but was unremarkable. Mechanical ventilation remained difficult due to abdominal pressure unless in the right lateral recumbent position. Ultrasound-guided paracentesis obtained 4 L of dark, viscous fluid over 1.5 hours. Post paracentesis, her oliguria and hypotension worsened. Unfortunately, she suffered a cardiac arrest and expired before she could be taken for mass removal

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