Teacher Education and Professional Development Commons^™

A Pediatric Case Of Treatment-Related Myelodysplastic Syndrome While On Therapy For Pre-B All, Sara Mcelroy

Research Days

Background: Treatment-related myelodysplastic syndrome (t-MDS) is a known, but rare, late effect of cancer therapy, specifically radiation, alkylating agents or topoisomerase II inhibitors. When secondary to treatment with alkylating agents, t-MDS typically occurs 4 to 7 years after therapy, and common cytogenetics include chromosomes 5 and 7 abnormalities. Treatment in children with t-MDS is typically allogeneic stem cell transplant, but the prognosis remains poor.

Objectives/Goal: To describe a rare case of a pediatric patient who developed t-MDS while receiving treatment for Pre-B Cell Acute Lymphoblastic Leukemia (pre-B ALL) and to outline the treatment regimen that he received.

Methods/Design: Case Report …

Therapeutic Plasma Exchange In Critically Ill Pediatric Patients With Leukemia, Sarah E. Mc Dermott, Chandni Dargan

Research Days

Background: Therapeutic plasma exchange (TPE) has well-documented applications in the adult population, outlined by the American Society of Apheresis (ASFA) 2019 guidelines. Limited data exists regarding the use of TPE in critically ill pediatric patients, however these reports rarely include patients with oncological diseases. Care for these patients poses certain clinical considerations including the safety of continuing chemotherapy, delayed clearance of chemotherapy secondary to end organ damage and mechanical clearance (i.e., continuous renal replacement therapy (CRRT) circuitry), and ability to tolerate chemotherapy once recovered. We aim to highlight the potential benefits of TPE in their acute management, so that it …

Outcomes Of Infants With Severe Rop At Risk Of Treatment With Avastin Compared To Laser Surgery, Stephen Doxey

Research Days

Background: Retinopathy of prematurity (ROP) is a well-known complication occurring in the most premature infants leading to visual impairment and in the most severe cases associated with retinal detachment and childhood blindness. Factors contributing the development of ROP include chronic hypoxia and disordered vascular genesis primarily through the vascular endothelial growth factor (VEGF) signaling pathway. Infants at risk of developing ROP are screened with serial eye exam and treated with either laser surgery or intraocular injects of bevacizumab (Avastin) to prevent progression of ROP and preserve vision. Bevacizumab, an inhibitor of VEGF signaling, may have positive effects on preventing ROP …

Long-Term Outcomes And Satisfaction Rates After Costal Cartilage Resection For Slipping Rib Syndrome, James Fraser

Research Days

Background/Objectives/Goal: Slipping rib syndrome (SRS) is a challenging and underdiagnosed condition that has proven to be an elusive diagnosis due to an extensive differential with presenting symptoms that mimic a myriad of alternative diagnoses of both thoracic and abdominal pathology. The diagnosis of SRS is recognized in a patient with consistent, progressive, often debilitating unilateral or bilateral chest wall and/or upper abdominal pain with intermittent clicking or rib slipping. SRS frequently does not resolve with conservative management, including physical therapy, rest, and NSAIDs, as well as intercostal injections, and even opioid medications. Workup can be extensive including multiple subspecialty referrals …

Multimodal Pain Control In Common Neonatal Surgeries: Post-Operative Pain Protocol Reduces Opiate Exposure And Side Effects, Jamesia Donato

Research Days

Background: Opioids are the primary post-operative (post-op) analgesic in neonates. Side effects include hypotension, apnea and ileus. Previous studies show IV acetaminophen decreases opiate need in specific populations including cleft palate repair, cardiac surgery. The effect of IV acetaminophen as part of a post-op pain algorithm is not known in common neonatal surgical procedures.

Objectives/Goal: To determine if (a) a post-op pain algorithm including IV acetaminophen and (b) IV acetaminophen exposure reduces cumulative opioid requirements in neonates undergoing common surgeries in the NICU.

Methods/Design: This is a retrospective cohort study comparing cumulative post-operative opiate exposure between infants with common surgeries …

Improving Thromboprophylaxis In Hospitalized Pediatric Inflammatory Bowel Disease Patients- A Quality Improvement Project, Amy Issa, Panam Kaur

Research Days

Background/Project Intent (Aim Statement): Pediatric inflammatory bowel disease (IBD) patients in acute flare have 1.5 to 3-fold higher risk of thromboembolism compared to the general population. Anticoagulation therapy is recommended for pediatric IBD patients who have ≥ 1 risk factors for venous thromboembolic events. At Children’s Mercy Hospital (CMH), approximately 80 patients/year are admitted for acute flare, of which, roughly 30% receive appropriate thromboprophylaxis. Lack of standardization of thromboprophylaxis and an educational gap amongst providers are significant barriers. Our goal is to standardize and improve the rates of thromboprophylaxis in IBD patients admitted at CMH from 30% to 60% by …

Umbilical Access In Laparoscopic Surgery In Infants Less Than 3 Months: Single Institution Retrospective Review, James Fraser

Research Days

Background/Objectives/Goal: Umbilical access in laparoscopic surgery has been cited as a potential factor for increased complications in low-birth-weight infants and those less than three months old. Previous series noted a self-reported complication rate of 10.6% among 329 pediatric surgeons via anonymous survey, citing carbon dioxide (CO2) embolism as the most common complication. We report four-year outcomes with blunt transumbilical laparoscopic access to examine the safety of this technique.

Methods/Design: Following IRB approval, a retrospective database of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016-2019 at a tertiary care academic center was …

Pediatric Pulmonary Artery Aneurysms Causing Pulmonary Hemorrhage: A Case Of Transcatheter Intervention While On Va Ecmo Support, Igor Areinamo

Research Days

Background: The incidence of pulmonary artery aneurysm (PAA) in children remains unknown. There are few reports of a transcutaneous interventional approach to address this type of pathology. Management of PAAs while on VA ECMO has not been described in pediatrics.

Objectives/Goal:

Methods/Design:

Case: 9-year-old previously healthy male presented with MRSA associated ARDS and sepsis requiring urgent VA ECMO cannulation. Chest CT done on ECMO day 22 showed development of right sided PAAs. Patient had an episode of significant pulmonary hemorrhage. Angiogram demonstrated two fusiform right PAAs, one of which had ruptured and was bleeding into the lung parenchyma. Patient had …

Not-So-Apparent Mixing Lesions: Late Presentation Of Cardioembolic Stroke, Amulya Buddhavarapu

Research Days

Background: Multiple levels of inter-atrial shunting can rarely present late in life with dyspnea and embolic stroke from effects of bidirectional shunting.

Case: A 55-year-old male with history of a patent foramen ovale, atrial fibrillation and embolic stroke presented with worsening fatigue and dyspnea at rest. Echocardiogram showed mildly reduced ventricular function with severe right heart dilation. On transesophageal echo, the coronary sinus (CS) was severely dilated with a persistent left superior vena cava (LSVC). A stress test showed no perfusion defects. CT angiography showed an absence of right SVC and a single LSVC connecting to the CS. There was …

Congenital Mitral Valve Regurgitation, The Dilemma Of Repair Vs Replacement., Bianca Cherestal

Research Days

Background: Congenital mitral regurgitation is a rare condition and can be challenging to manage when presenting in the neonatal period

Objectives/Goal: Two week old male presented with poor weight gain, murmur and cardiomegaly on chest X-ray. Echocardiogram showed moderate to severe mitral regurgitation (MR) and suprasystemic pulmonary hypertension (PHN) (fig 1 a, b). The mitral valve (MV) leaflets were thickened and tethered with failure of central coaptation. PHN was classified as WHO I and II (due to persistent PHN of newborn and MR respectively). Inhaled nitric oxide, Enalapril and Furosemide were initiated. Cardiac catheterization revealed PVRi of 8.9 WU x …

Online Echocardiography Modules For Pediatric Cardiology Fellows, Sarah Studyvin, Doaa Aly, Tyler Johnson, Laura Kuzava, Alison Samrany, Nitin Madan, Sanket Shah

Research Days

Background: Adequate echocardiographic (echo) education is integral to successful cardiology training. Online education is proven to be effective in other specialties, but pediatric echo training data are lacking.

Objectives/Goal: Our aim was to design and assess the role of a novel online module-based curriculum to enhance pediatric cardiology fellows’ echo education.

Methods/Design: Four interactive modules, focused on principles and interpretation of a normal echo, were delivered to fellows. Content included high quality 2D and 3D echo clips as well as interactive quizzes and could be accessed from a phone, tablet, or computer. All fellows completed pre- and post-tests, validated by …

Constrictive Pericarditis After Repair Of A Ruptured Sinus Of Valsalva, Sarah Studyvin, Laura Kuzava

Research Days

Background: Constrictive pericarditis is an uncommon complication of cardiac surgery. We report a patient who developed constrictive pericarditis after ruptured sinus of Valsalva (RSOV) repair.

Methods: A 23-year-old male presented with exertional dyspnea one year after RSOV repair. TTE showed a small, circumferential effusion with thickened pericardium, ventricular septal bounce, left atrial enlargement, diastolic hepatic flow reversal, and trivial mitral regurgitation without stenosis. He underwent cardiac catheterization, which revealed elevated filling pressures (RVEDP 16 mmHg, LVEDP 18 mmHg), RVEDP/RVSP ratio < 0.5, and a low cardiac index (1.65 L/min/m2). Cardiac MRI confirmed pericardial thickening with paradoxic septal motion, dilated pulmonary veins and retrograde flow in the SVC.

Results: Pericardiectomy of thickened and adherent pericardium was performed. The central venous pressure decreased from 23 to 7 mmHg and …

Creating A Democratic Mathematics Classroom: The Interplay Of The Rights And Responsibilities Of The Learner, Priya V. Prasad, Crystal Kalinec-Craig

Democracy & Education

One way in which democratic classrooms can reflect a democracy is by guaranteeing students some inalienable rights; Kalinec-Craig (2017) outlined Olga Torres’s Rights of the Learner (Torres’s RotL) in mathematics classrooms. However, democracies rely not only on citizens’ rights, but on their willingness to take up certain responsibilities as well. We extend this idea to mathematics classrooms to explore the consequences of the interplay of learners’ rights and responsibilities, in the context of the preparation of elementary mathematics teachers. In addition, we explore ways in which learners may overexercise their rights of the learner or opt out of exercising them …

Local Implementation And Standardization Of The Pediatric Severe Traumatic Brain Injury Guidelines, Michelle Brown

Research Days

Problem Statement/Question: Severe pediatric Traumatic Brain Injury (TBI) remains a significant cause of morbidity and mortality. Evidence-based guidelines leave gaps in how to best implement and deliver standardized care on the local hospital level.

Background/Project Intent (Aim Statement): We aim to improve clinical outcomes for severe TBI patients (Glasgow Coma Scale ≤8) with standardization of care according to updated evidence-based guidelines. We will target early guideline adherence (initial 72 hours of PICU admission) with a focus on 1) targeted temperature management (TTM40mmHg).

Methods (include PDSA cycles): The Children’s Mercy Hospital Pediatric ICU Severe TBI Guidelines were updated after the 3rd …

Simulation Based Clinical Systems Testing Of A Pediatric Ed To Improve Staff And Process Readiness For Pediatric Hypoglycemia, Kevin Meilak Md

Research Days

Background/Project Intent (Aim Statement): Hypoglycemia is the most common metabolic disorder in children in pediatric emergency department (ED) settings 1 . Children may present with nonspecific symptoms, or asymptomatically2 . So identification/treatment is very challenging. There is evidence in the adult literature that there is wide variability in the treatment of hypoglycemia3 . Currently Children’s Mercy does not have a standardized approach to the treatment of hypoglycemia not associated with diabetes mellitus. From observation in the clinical setting we believe there are gaps regarding the identification and treatment of hypoglycemia not associated with diabetes mellitus. Delayed recognition and under treatment …

Optimization Of Perioperative Prophylaxis In Penicillin-Allergic Labeled Patients, Katie A. Vandervelde

Research Days

Problem Statement/Question: A penicillin (PCN)-allergy label is life-long and has been shown to result in more costly, less effective, and broader-spectrum antibiotics being utilized for surgical prophylaxis. At CMH, 6.6% of surgical patients receiving perioperative antibiotics are labeled PCN-allergic. A common myth is that approximately 10% of patients with a PCN-allergy history will experience an allergic reaction if administered a cephalosporin, whereas recent observational studies have found crossreactivity rates between 0.17-0.7%. Most of these patients receive a cefazolin alternative unnecessarily. Currently, no process exists to identify and clarify PCN-allergic patients preoperatively. Data from November 2018-December 2019 found ~2.33 patients per …

A Case Of Metabolic Genetic Emergency, Elizabeth Loughman

Research Days

Background: Newborn screening (NBS) is one of the largest public health initiatives to improve infant morbidity and mortality, and this has been shown to detect and lead to prompt treatment of uncommon but rapidly fatal conditions. While NBS has changed outcomes of diseases, it is still imperative that prompt and early recognition of abnormal results and medical interventions remain the mainstay of care.

Objective: To describe a case of inborn error of metabolism in a 4-day old asymptomatic infant, where early recognition and treatment affected outcome.

Design/Methods: This case is a 4-day old female, former 36-week gestational age infant who …

Association Between Blood Pressure And Esa Dose In Pediatric Patients On Dialysis, Heather A. Morgans

Research Days

Background: Hypertension is a reported side effect of Erythropoiesis Stimulating Agents (ESAs), with a mechanism of action related to elevated hematocrit levels and direct vasopressor effects. Limited information exists on the relationship between ESA dosage and hypertension in children receiving maintenance dialysis.

Objectives/Goal: The primary aim of this study was to determine whether there is a significant association between ESA dose and blood pressure (BP) in pediatric patients on dialysis. The secondary aim was to determine covariates in relation to ESA dose.

Methods/Design: Data from the International Pediatric Dialysis Network (IPDN) database was used to retrospectively analyze the association between …

Functional Outcomes Of Infants With Chiari Ii Malformation With Tracheostomy And Home Ventilator Dependence, Abbigayle Carlson

Research Days

Background: Chiari II malformation is relatively common with an incidence of about 1 in 1000 live birth and is associated with reduced life expectancy. Characteristic features are beaked midbrain, downward displacement of the tonsils, and cerebellar vermis, and spinal myelomeningocele that can be associated with hydrocephalus needing ventriculoperitoneal shunt (VP shunt). Mortality is about 50-70% if not recognized early. Survivors have high morbidity and develop neurologic abnormalities and significant developmental delays. Long-term outcome is poorly understood.

Objective: Not much has been published that describes the outcome of infant with Chiari II malformation that received tracheostomy for long-term ventilator support. Our …

Evaluation Of A Symptom-Based Algorithm For Managing Battery Ingestions In Children, James Fraser

Research Days

Background/Objectives/Goal: Complications from battery ingestion in the pediatric population are becoming more severe due to the emergence of stronger and smaller batteries. We previously established a symptom-focused, evidence-based algorithm for battery ingestion and seek to evaluate this protocol to investigate its safety and potential cost benefit. (Figure 1)

Methods/Design: Following IRB approval, all radiographs performed for foreign body ingestion between 2017-2020 were reviewed. All button battery ingestions were included to evaluate an institutional symptom-based algorithm emphasizing observation over intervention.

Results: Review of 2,237 foreign bodies series demonstrated 44 button battery ingestions. Median age at ingestion was 3.8 years [2.5,5.2]. Locations …

Phenotypic Characterization Of Jarid2-Related Intellectual Disability: A Case Series, Maxime Cadieux-Dion

Research Days

Background: In recent years, wide implementation of research and clinical next generation sequencing has led to an astonishing number of novel disease-gene assertions. Recently, loss of function variants in JARID2 were reported in 16 patients with a clinically distinct neurodevelopmental phenotype that consisted of neurodevelopmental delay, intellectual disability (ID), learning disability, autism and behavioral abnormalities. Dysmorphic features were seen in most patients and included high anterior hairline, deep-set eyes, full lips, broad forehead, bulbous nasal tip, or depressed nasal bridge. Cleft lip/palate was observed in only 1/16 patients. Most cases were de novo, with only one inherited case from an …

Environmental Topics In Physics By Inquiry Course: Integration Models Used By Physics Teachers, David A. Kimori, Gillian Roehrig

The Qualitative Report

As we approach the second quarter of the twenty-first century, one may predict the environment will be among the dominant themes in political and educational discourse. This study investigates how three physics teachers integrated environmental topics and issues in their classroom. Data collection methods including field notes taken from observations, teachers’ interviews, and a collection of artifacts and documents were used. The data were coded, analyzed, and organized into categories utilizing Fogarty’s models of curriculum integration. Findings of this study indicate teachers acknowledge the importance of teaching environmental issues in their classrooms; however, implementing and utilizing effective integration strategies and …

Educational Impact Of Supervising Fellow Visits In The Emergency Department, Grace E. Arends Md

Research Days

Problem Statement/Question: After meeting certain criteria, pediatric emergency medicine (PEM) fellows were previously permitted to independently manage and discharge patients. These encounters anecdotally fostered autonomy but missed educational opportunities. We have previously reported that fellow positive perception of education and autonomy was low (22% and 11%). Additionally, the absence of an attending’s attestation on these patient charts prevented the collection of a professional service fee, an average potential billed amount of $125.67 per unit of service or total of $620,307 in 2019.

Background/Project Intent (Aim Statement): After key stakeholder involvement, we recognized attending supervision for all fellow patients as an …

Smart Rounding: Development Of A Nurse-Driven Rounding Checklist As A Sustainable Intervention For Improved Care Communication, Charles I. Maloy

Research Days

Background/Project Intent: Use of checklists in the healthcare setting is increasingly common and is important to the development of high reliability and standard avenues for communication. At our tertiary care freestanding pediatric hospital, there was no widely used rounding checklist that discussed items important to quality care and patient safety outside of the intensive care unit. The development and implementation of medical checklists for the standard patient floor are inadequately described. We will develop and implement a rounding checklist with at least 80% daily checklist use sustained over 6 months. Team members will report improved multidisciplinary discussion of patient safety …

Educating Providers: Timely Post-Operative Pain Management In A Level Iv Neonatal Intensive Care Unit (Nicu), Jamesia Donato, Jamesia Donato

Research Days

Background/Project Intent (Aim Statement): NICU patients often encounter painful procedures and can have significant short and long-term consequences from inadequately treated pain. Ensuring adequate pharmacological and nonpharmacological pain management while minimizing associated risks is paramount. Our NICU is part of the Children’s Hospitals Neonatal Consortium “Erase Pain” collaborative to improve management of postop pain in neonates. SMART Aim: Increase the percentage of patients receiving acetaminophen within one hour after surgery to greater than 70% by July 2020.

Methods (include PDSA cycles): A multidisciplinary team developed pain treatment algorithms and postop order plans to standardize the approach to postop pain management. …

Improving The Approach To Fellowship Trainee Feedback, Katie A. Vandervelde

Research Days

Problem Statement/Question: Giving and receiving feedback are difficult but necessary skills in medical training. We identified a need for improved feedback based on decreased learner satisfaction on our annual ACGME survey. In an anonymous survey, 2018-19 infectious disease fellows reported receiving formal feedback from 52.4% of their inpatient clinical experiences with faculty.

Background/Project Intent (Aim Statement): Increase the occurrence of feedback to fellows by faculty during clinical service rotations from 52.4% to >90.0% in 6 months utilizing a standardized method.

Methods (include PDSA cycles): A Feedback Card (Figure 1), was developed by fellows and faculty. Both parties were instructed to …

Does Access To Care Influence A Child’S Presentation With Appendicitis?, Neal Talukdar

Research Days

Background + Objectives/Goal: Racial demographic and health care coverage impact how and when patients seek care. Previous studies have documented that minority children present with higher rates of perforated appendicitis. We aimed to identify if racial and coverage disparities were associated with the timing and mechanism of appendicitis presentation.

Methods/Design: We performed a prospective study of children (≤ 18 years old) who underwent laparoscopic appendectomy from May 2018 - September 2020. Prior to discharge, the patient’s parent/guardian completed a survey focused on health care encounters within the past year. Surveys were collected using RedCap®; data were analyzed using STATA®.

Results: …

Standardization Of Fertility Preservation Discussion Amongst Pediatric Oncology And Bone Marrow Transplant Patients: A Single Institution Experience, Chandni Dargan, Sarah E. Mc Dermott, Shelby Chesbro

Research Days

Background/Project Intent (Aim Statement): As treatment for pediatric malignancies improves long term survival, physicians are shifting focus to late effects of therapy such as infertility. Currently, options for fertility preservation include cryopreservation of mature oocytes, sperm, and gonadal tissue, although barriers remain present. Within our division, we lacked a standard approach to discussing fertility preservation options prior to initiation of treatment.

Methods (include PDSA cycles): Records from 474 pediatric patients with new oncologic diagnoses at CMH from 2014- 2020 were retrospectively reviewed. We evaluated the frequency that reproductive health discussions were documented in pubertal males and females requiring chemotherapy or …

Esophageal, Gastric, And Duodenal Histologic Findings In Patients With Feeding Difficulties, Amy Issa

Research Days

Background: The etiology of feeding difficulties in children is often multifactorial including medical, oral motor, and behavioral. Gastrointestinal etiologies have been identified as the primary medical component in children with feeding difficulties, however, there is not substantial information to predict which children will have a particular gastrointestinal disorder. The general consensus has been that children with feeding difficulties should have symptoms such as vomiting or abdominal pain to warrant performing esophagogastroduodenoscopy (EGD), but the validity of this approach has not been established.

Objectives/Goal: The aims of the current study were to describe EGD findings of patients presenting to a large …

Efficacy Of Pediatric Surgery Mobile Application For General Surgery Residents, James Fraser

Research Days

Background/Objectives/Goal: Integration of pediatric surgery content into the general surgery curriculum poses unique challenges as the patient population, pathophysiology, and management of surgical disease is distinctive from other subspecialties. Pediatric surgery represents approximately 2% of content on the in-training exam for residents (ABSITE) and is often underemphasized in didactic material, contributing to difficulty with preparation for these clinical rotations. We hypothesize that implementation of a mobile-based application with pertinent clinical algorithms and resources for pediatric surgical education will improve resident performance and enhance learning experiences in the management of pediatric surgery patients.

Methods/Design: Seventeen residents rotating on the pediatric surgery …