Teacher Education and Professional Development Commons^™

Relationship Between Rurality And Access To Care For Families Of Hospitalized Children, Zoetta L. Mcloughlin Md

Research Days

Background: At Children’s Mercy Hospital, greater than 1 in 5 hospitalized children are from rural areas. Rural families often travel long distances for hospitalization at free-standing children’s hospitals, a median of 70 miles according to recent work. Rural families are more likely than non-rural families to experience financial insecurity, and these baseline hardships may be intensified during hospitalization due to out-of-pocket costs, lost work, inability to meet family needs, and removal from social support. However, little is known about the differences in healthcare access and resulting burdens between rural and non-rural families.

Objectives/Goal: To describe differences in demographics, health care …

Rural And Urban Caregiver Experiences Of Financial Strain And Food Insecurity During Pediatric Hospitalizations, Rachel E. Granberg

Research Days

Background: Stress is common among caregivers of hospitalized children. In addition to stress related to their child’s illness, caregivers experience stress related to financial strain and food insecurity during their child’s hospitalization. The burden of financial strain and food insecurity related to pediatric hospitalizations may vary between rural and urban populations.

Objectives/Goal: To identify financial strain and food insecurity experienced by caregivers of hospitalized children and to describe differences between rural and urban populations.

Methods/Design: A prospective cross-sectional survey enrolled a random sample of caregivers of hospitalized children between 8/31/2021 and 12/2/2022 at a single children’s hospital. Demographic information was …

Female Authorship Concordance In Academic Pediatrics, Roxana Guggenmous, Jessica L. Bettenhausen, Jessica L. Markham

Research Days

Background: Gender disparities are well described in medicine and academia. Despite a catalyzed movement towards gender equity, female physician-scientists remain at risk for experiencing biases in hiring practices, compensation, promotion, appointment to leadership positions, and achievement of extramural funding through the National Institutes of Health. In pediatrics, the female workforce has grown consistently over time, with female physicians comprising 72.3% of the workforce as of 2021, yet prior work suggests that this growth is not fully reflected in academic publications. Achieving gender parity in academic publication may help reduce gender-based disparities impacting career advancement. Therefore, we sought to describe the …

Pediatric Educational Outreach To A Community Based Emergency Department: Clinical Management Of The Febrile Infant, Jess Parker, Frances Turcotte Benedict, Emily Hillman, Ryan C. Jacobsen, Ashley K. Sherman, Arjun Sarin

Research Days

Background: Multiple studies have shown variability in the approach to treatment of febrile infants ≤ 60 days of age in community emergency departments (EDs), and the American Academy of Pediatrics (AAP) recently published new guidelines on management of febrile infants. Therefore, an opportunity exists to provide evidence-based recommendations for the care of this patient population to providers in community EDs.

Objectives/Goal: To assess 1) alignment of community ED provider practices with an AAPinformed Clinical practice guideline (CPG) for management of febrile infants ≤ 60 days of age. 2) change in comfort level and degree of alignment after targeted education.

Methods/Design: …

Socioeconomic Factors And Picu Interventions In High Mortality Risk Asthmatics, Hanh Ho, Paul N. Bauer, Jade B. Tam-Williams

Research Days

Background: Asthma mortality rates are overall lower in children, but studies estimate 5-10% of asthmatics have refractory mortality prone asthma. Asthmatics with repeat pediatric intensive care unit (PICU) admissions are believed to be at high mortality risk with increased health care utilization and socio-economic challenges.

Objectives/Goal: We aim to identify patients with repeat PICU admissions for status asthmaticus and characterize the levels of interventions and socio-economic status.

Methods: A retrospective chart review was done on patients with the following inclusion criteria: age 0- 18, PICU admission between January 2010 to December 2015, and a diagnosis of status asthmaticus on admission. …

Supporting Families Impacted By Adverse Childhood Experiences (Aces), Jennifer Paumen, Laura Plencner, Jacqueline Kitchen

Research Days

Background: Adverse childhood experiences (ACEs) impact a majority of individuals, with approximately two-thirds of adults having experienced 1 or more ACE.1 The health consequences of ACEs are significant, including cardiovascular disease, cancer, autoimmune diseases, and mental illnesses.1 These health impacts can even start as early as childhood, leading to an increased risk of learning and behavioral concerns.2,3 Recent evidence has also identified the impact that parental ACEs may have on parenting and child development,4,5,6 which in turn may lead to an intergenerational transmission of ACEs.4,7 As a nurturing caregiver relationship is key for buffering adversity,2,8 it is imperative to address …

Influencing Influenza Immunization: Qi Project In A Pediatric Resident Continuity Clinic, Brittany Moore

Research Days

Problem Statement/Question: There have been a multitude of approaches to vaccine hesitancy in regard to childhood vaccinations. In light of the COVID-19 pandemic there was a noticeable decline in influenza vaccination among children aged 6 months to 18 years. The influenza vaccination rate in the pediatric resident continuity clinic at Children’s Mercy Hospital was below the national average for pediatric patients.

Background/Project Intent (Aim Statement): The aim of this study is to increase the percentage of patients aged 6 month and older currently enrolled in ROYAL clinic receiving at least one influenza vaccine from 38.6% to 55% by January 1, …

Increasing Utilization Of Gestational Age Based Table For Initial Intubation In A Level Iv Neonatal Intensive Care Unit, Maribel Martinez, Dianne Lee, Christopher R. Nitkin

Research Days

Problem Statement/Question: Most providers in our unit are not using the NRP recommended method to determine the initial ETT insertion depth in neonates.

Background/Project Intent (Aim Statement): Endotracheal tube (ETT) depth in neonates is of critical importance due to significant adverse events when malpositioned. While randomized trials comparing different methods have not shown superiority of any particular method, the weight-based method (weight (kg) +6) has been found to be highly inaccurate in extremely low birth weight neonates. Furthermore, the Neonatal Resuscitation Program (NRP) recommends using gestational age (GA)-based table (Kempley ST, et al, Resuscitation 2008) or nasal-tragal length for initial …

Improving Frequency Of Peer Review Of Abnormal Genital Exam Findings In Patients Undergoing Sexual Abuse Evaluation, Lyndsey Hultman, Julia G. Harris, Terra N. Frazier, Jennifer B. Hansen

Research Days

Problem Statement/Question: Child Advocacy Centers (CACs) coordinate child abuse MDTs, and 2023 CAC accreditation standards require that “all medical professionals providing services to CAC clients must demonstrate that 100% of all findings deemed abnormal or “diagnostic” of trauma from sexual abuse have undergone expert review by an advanced medical consultant.” Scheduled Case Review occurs among Children’s Mercy child abuse pediatricians (CAPs), but current practice is to review cases only upon CAP request.

Background/Project Intent (Aim Statement): Appropriate interpretation of sexual abuse exam findings is crucial for accurate diagnosis and provision of medical information to multidisciplinary child protection teams (MDTs). Medical …

Unique Endoscopic Retrieval Of A Large Rectal Foreign Body, Laurie Mccann, Jose Cocjin

Research Days

Introduction: Large rectal foreign bodies are usually difficult to extract, usually requiring operative management.

Case: A 14-year-old male presented to the ER for a rectal foreign body. Earlier in the day, he had rectal itching and inflammation. He used a cylindrical reusable ice stick (for water bottles) for topical relief, which did not work, so he placed the tube in his rectum, then he was unable to retrieve it and sought medical help. Physical exam was significant for lower abdominal pain and palpable mass just below his umbilicus, which was painful to palpate. CT abdomen/pelvis showed a large foreign body …

Improving Fluid Management Of Extreme Premature Infants By Providing A Restrictive Fluid Management Algorithm In The Nicu, Jacob S. Ward, Dena Hubbard, Nicholas Clark

Research Days

Problem Statement/Question: At our institution we found wide variability in and a lack of an evidence-based standard for fluid management in premature infants.

Background/Project Intent (Aim Statement): Excessive fluid intake in premature infants during the first week of life increases the risk of adverse events and overall mortality. Fluid restriction is recommended to help decrease morbidity and mortality in this patient population. We aimed to improve the fluid management of premature infants born < 29 weeks gestation admitted to our intensive care nursery (ICN) by implementing a fluid restriction protocol with the goal of >70% compliance over a 16-month period.

Methods (include PDSA cycles): Institution of daily weights started at beginning of baseline period. In April of 2021, we implemented a …

Hypereosinophilia With An Anterior Mediastinal Mass, Sonya Parashar, Aarti Pandya

Research Days

Background: Hypereosinophilia is defined as 1500 eosinophils/mL or above with evidence of end-organ damage due to the eosinophils at least 4 weeks apart.

Objectives/Goal: We describe a case of steroid resistant hypereosinophilia.

Methods/Design: A 3-year-old male was admitted for newly found anterior mediastinal mass and left pleural effusion. About 6 weeks prior to admission, he was seen in his primary care office for difficulty breathing. Despite the appropriate treatment for his symptoms, the patient continued to have significant respiratory symptoms and a chest x-ray showed a large left pleural effusion. He was immediately transferred to a tertiary care center and …

Bone Marrow Transplant For Macrophage Activation Syndrome In Systemic Juvenile Idiopathic Arthritis, Shailly Gaur, Michael J. Holland, J Allyson Hays, Ibrahim A. Ahmed

Research Days

Background

The recognition of macrophage-activation-syndrome (MAS) in the setting of systemic-juvenileidiopathic-arthritis (sJIA) is complex, but a necessary distinction given emerging treatment options. With overlapping clinical manifestations including fever, end-organ involvement and lymphadenopathy, there is a focus on laboratory values to differentiate MAS from a sJIA flare. Once parameters are met, multiple treatment modalities can be considered, as monotherapy or in combination, including steroids, immunosuppression, chemotherapy, intravenous immunoglobulin, and cytokine-directed biologics. Given the long-term morbidity and mortality associated with progressive inflammation and immune dysregulation due to MAS with sJIA, it is imperative to regain control over this complication. However, these treatments …

Variation In Thiopurine Metabolism In Hispanic Children, Kayeleigh Higgerson Do

Research Days

Background: Acute lymphoblastic leukemia (ALL) is the most common childhood cancer. Overall survival rate is > 90% in the United States. However, ethnic and racial disparities remain. Hispanic patients have an inferior overall survival compared to non-Hispanics. The reasons for these differences remain unclear. Mercaptopurine (6MP) is a crucial drug in ALL treatment. Variations in the TMPT and NUDT15 genes lead to altered 6MP metabolism and accumulation of toxic metabolites (6TGN or 6MMPN). Each metabolite is associated with specific dose-limiting toxicities. The accumulation of 6TGN causes myelosuppression, and increased 6MMPN causes GI toxicity. While variants in these genes have been identified …

Potassium Status In Pediatric Chronic Kidney Disease, Katherine L. Kurzinski

Research Days

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Background: Potassium trends are well described in adult chronic kidney disease (CKD) and hyperkalemia is known to be associated with increased disease progression, morbidity, and mortality. Large scale studies assessing potassium trends and the prevalence of hyperkalemia in pediatric CKD have not been performed.

Objectives/Goal: We aimed to characterize median serum potassium levels and the prevalence of hyperkalemia for each CKD stage using the CKiD cohort. The relationship of serum potassium and hyperkalemia with patient demographics, CKD etiology (glomerular or non-glomerular), presence of acidosis, and degree of proteinuria was also evaluated.

Methods/Design: Median serum potassium …

Association Of Rare Variants In Kidney Developmental Genes With Hypertension And Ckd: A Uk Biobank Study, Benjamin L. Spector

Research Days

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Background: Prior studies show chronic kidney disease (CKD) is heritable but only a few common variants have been associated with CKD and kidney dysfunction. Much of CKD heritability remains unknown and limited studies have explored the role of rare genetic variants in this missing heritability.

Objectives/Goal: Identify rare genetic variants in renal developmental genes associated with hypertension and CKD.

Methods/Design: We examined the association between rare variants in 58 candidate genes from five renal developmental compartments and presence of CKD and elevated blood pressure (BP) in 49,989 individuals using whole exome sequencing and phenotypic data …

Treatment Of Recurrent Wilms Tumor With Irinotecan/Temozolomide, Meagan Vacek

Research Days

Background: Despite improvement in relapse free survival (RFS) in recurrent Wilms tumor, the 4- year RFS rate for patients treated with vincristine/dactinomycin/doxorubicin is approximately 40%. Ifosfamide, carboplatin and etoposide are commonly used in relapsed solid tumors but have significant toxicities and require hospital admission for administration. Our patient focused on quality of life, and this led to exploration of other treatment options.

Objectives/Goal: Describe a case of multiply relapsed Wilms tumor with management on oral chemotherapy for improved quality of life and remission for almost 1 year.

Methods/Design: Case Report

Results: The patient is an 11-year-old female diagnosed with Wilms …

Increasing Incentive Spirometry Use In Patients With Sickle Cell Disease Admitted To Children’S Mercy Hospital, Thomas Cochran, Alexandra Prosser

Research Days

Background: Acute chest syndrome is one of the leading causes of morbidity and mortality in patients with sickle cell disease. The National Heart, Lung, and Blood Institute (NHLBI) provides specific recommendations for providing ten breaths of incentive spirometry (IS) every two hours while awake for patients with sickle cell disease to help prevent development of acute chest syndrome.

Problem Statement: We reviewed provision of incentive spirometry at Children’s Mercy between 08/01/2021 and 11/01/2021. Data was collected and the target population was identified via a report generated from the electronic medical records with specific criteria. Of those patients admitted with sickle …

Wilms Tumor Presenting With Spontaneous Necrosis And Clostridium Perfringens Co-Infection, Ronald Palmen, Abbey Elsbernd, Kristin Palmen

Research Days

Background: Wilm’s Tumor (WT) is the most common renal malignancy of childhood. The initial presentation of WT may mimic infection or other malignancies with nonspecific symptoms including fever, abdominal/flank pain, or hematuria. This poses a diagnostic challenge for providers, particularly when both infection and malignancy are observed. We describe a case of WT with spontaneous necrosis initially obscured by overlying Clostridium perfringens infection, making diagnosis of the cancer difficult.

Case Description: A previously healthy 5-year-old girl presented to the emergency department with a two-day history of left flank pain and fevers. In the emergency department, she was tachycardic (130 bpm), …

Acute Complications In Pediatric Patients With Diabetes Admitted With Isolated Diabetic Ketoacidosis, Isolated Hyperglycemic Hyperosmolar State, And Mixed Hyperosmolar Diabetic Ketoacidosis, Erica Zarse

Research Days

Background: Diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), and mixed DKA and HHS (hyperosmolar DKA) are hyperglycemic emergencies for which children with diabetes mellitus (DM) are admitted to the hospital. To date, there is little evidence to guide the management of pediatric diabetic patients with hyperosmolarity.

Objectives: The objective of this study is to compare the in-hospital complications at our institution in patients who have isolated DKA to those with a component of hyperosmolarity.

Methods: We reviewed medical records of patients from 01/2019 through 12/2020 admitted with DKA (serum bicarbonate ≤16 mEq/L) and/or HHS (blood glucose ≥600 mg/dL and osmolality …

Memory T Cell Populations In Human Leukemia, Sara Mcelroy

Research Days

Background: Incorporating the immune system into cancer management is an area of robust research. Treatment modalities aimed at activating cytotoxic T cells against malignancies include immune checkpoint inhibitors, bispecific T-cell engagers, and chimeric antigen receptor (CAR) tumor-specific T cells. Most anti-cancer T cell research is narrowly focused, but knowledge about the nature of diverse sub-populations of T cells in cancer, particularly memory T cells, is vital prior to potential incorporation into therapies. T memory stem cells (Tscm) are of interest due to their longevity and powerful abilities of self-renewal and creating the full spectrum of memory CD8+ T cells, including …

Quality Improvement Project To Improve Provider-To-Nursing Communication During Daily Rounds, Kayeleigh Higgerson Do, Sara Mcelroy Md

Research Days

Problem Statement/Question: We aim that by June 2021, our Heme/Onc resident service daily table rounds will include 80% of bedside nurses to improve communication between the provider team and bedside nurse.

Background/Project Intent (Aim Statement): Daily rounds on our Heme/Onc resident service include table rounds (discussion of overnight events and daily plan) and bedside rounds (team goes to see patients and relay daily plan). These rounds infrequently include the bedside nurse caring for the patient, leading to poor communication of the plan from the provider team. This is a problem, because it has the potential to lead to medical errors …

Acute Kidney Injury In Youth With Diabetes Admitted With Isolated Diabetic Ketoacidosis, Isolated Hyperglycemic Hyperosmolar State, And Hyperosmolar Diabetic Ketoacidosis: A Single Center Experience, Erica Zarse

Research Days

Background: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are hyperglycemic emergencies for which children are admitted to the hospital.

Objectives/Goal: Our objective was to compare acute kidney injury (AKI) between youth with isolated DKA to those with hyperosmolarity and explore associations to risk of AKI.

Methods/Design: Charts were reviewed from 01/2019 through 12/2020 for youth admitted with DKA (serum bicarbonate ≤16 mEq/L) and/or HHS (blood glucose ≥600 mg/dL and osmolality ≥320 mOsm/kg). Isolated HHS youth were combined with hyperosmolar DKA for analysis. AKI was defined as elevated creatinine level for age. The total amount of isotonic fluids administered was …

The Racial And Ethnic Makeup Of The Asthma Clinical Trials Informing The 2020 Nhlbi Asthma Guidelines Update, Esosa Adah

Research Days

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Rationale: Black/African American and Hispanic people in the United States are disproportionately impacted by asthma with increased prevalence, morbidity, and mortality. However, these groups are often under-represented in asthma clinical and translational research studies which is a barrier to achieving health equity. We describe the racial/ethnic makeup of participants included in clinical trials which informed the recent 2020 National Heart, Lung, and Blood Institute(NHLBI) asthma management guidelines focused update.

Methods: We identified clinical trials included within the 2020 NHLBI asthma management guidelines focused update. We determined the frequency (%) of studies reporting study participant racial/ethnic …

Improving Advanced Therapeutic Endoscopy Performance At An Academic Children's Hospital, Julia Snodgrass, Thomas M. Attard, Donna Ditsch, John Colgan, Amanda Weston, Jessica Koch, Nadia Ibrahimi, Pang Krasaelap, Voytek Slowick, Laura Shroyer

Research Days

Problem Statement/Question: Advanced therapeutic endoscopy is infrequently needed but critical in the management of children with complex gastroenterology disorders. Hands-on experience in specific advanced techniques, set up of endoscopy equipment and familiarity with new ancillary equipment for use during endoscopy have been intra-departmentally identified as potential areas for improvement.

Background/Project Intent: Our aim is to improve provider scoring on an endoscopy practice test based on technical aspects of therapeutic techniques, indications and set up of standard and new endoscopic equipment by 20% over pre-practice session testing.

Methods: The Model for Improvement framework was utilized. A multidisciplinary team was created including …

A Case Of An Elevated Tryptase, Sonya Parashar

Research Days

Introduction: Hereditary Alpha Tryptasemia (HαT) is an autosomal dominant disorder characterized by an elevated baseline tryptase that occurs up to 3% of the population and clinically resembles mast cell activation syndrome.

Case description: A full-term, 13-month-old female patient presented to Allergy and Immunology clinic for persistently elevated tryptase. Her initial symptom was non-bloody loose stools, but she later developed recurrent flushing, joint pain, constipation, and frequent nighttime awakenings. Her past medical history included gastroesophageal reflux disease. Family history was significant for an older sibling with history of flushing. At all visits, physical examination was normal. Tryptase ranged between 11.7 - …

Evaluating Caretaker Satisfaction With Same-Day Discharge After Gastrostomy Tube Placement, James A. Fraser Md, Shai Stewart Md, Kayla B. Briggs Md, Shawn D. St. Peter Md, Tolulope A. Oyetunji Md Mph

Research Days

Background: Same-day discharge (SDD) after outpatient laparoscopic gastrostomy tube (G-tube) placement has been our standard institutional practice since 2017, following written and video-based preoperative education regarding G-tube use, maintenance, and exchange at the time of consultation.

Objectives/Goal: We aim to evaluate caretaker satisfaction with our same day discharge protocol following laparoscopic gastrostomy tube placement.

Methods/Design: Following IRB approval, all patients planned for SDD after G-tube placement from FebruarySeptember 2021 at a tertiary care academic center were identified. Retrospective chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length …

Ultrasound Guided Peripheral Iv Access Curriculum For The Pediatric Emergency Department: A Pilot Study., Samuel Dillman

Research Days

Background: Up to 50% of children have difficult venous access. Studies in the Pediatric Emergency department (PED) have shown that ultrasound guided peripheral IV (USGPIV) access has decreased IV access time and ED length of stay.  Barriers for use include lack of training and comfort with the procedure.

Objectives/Goal: Our objectives are to pilot and evaluate USGPIV training for Pediatric Emergency Medicine (PEM) physicians and nurses.

Methods/Design: The course included a 4-hour, hands-on session with US IV training using a blue phantom task trainer in conjunction with the Vascular Access Team (VAT) for PEM physicians and nurses.  Participants’ skills were …

Recurrent Primary Spontaneous Pneumothorax Masquerading As A Congenital Pulmonary Airway Malformation In A Young Female, Chandra Swanson

Research Days

Background: Spontaneous pneumothoraxes in children are uncommon, may be idiopathic or associated with underlying pulmonary disease, and can present management challenges.

Objectives/Goal: We present a 12-year-old female with recurrent right sided spontaneous pneumothorax in the setting of an asymptomatic SARS-Co-V2 (COVID) infection and imaging concerning for congenital lobar overinflation (CLO) versus congenital pulmonary airway malformation (CPAM), prompting surgical intervention.

Methods/Design: A literature review and chart review were completed for this case report.

Results: A 12-year-old pre-menstrual female with remote history of eczema, asthma, and environmental allergies presented from an outside facility with four-days of progressive chest pain and dyspnea on …

Factors Leading To Reduced Unscheduled Pediatric Asthma Visits During Covid-19, Sean Stout

Research Days

Background: Emergency Department (ED) and inpatient (IP) asthma visits were reduced during 2020 at a tertiary pediatric hospital. This was likely due to measures used to avoid exposure to the SARS-CoV2 virus which led to fewer viral upper respiratory infections (URIs). Other known asthma triggers include allergens, air pollution, and weather changes.

Objectives/Goal: To determine whether other factors could explain this reduction, we looked for changes in other asthma triggers such as pollen, air pollution, and weather.

Methods/Design: Monthly ED and IP asthma visits from 2010 to 2019 were compared to 2020 by time series analysis (TSA), controlling for total …