Medicine and Health Sciences Commons^™

Increasing Vaccination Rates Of 23-Valent Pneumococcal Polysaccharide Vaccine Among Patients At High-Risk For Invasive Pneumococcal Disease., Edward Lyon, Tracey Wetzel, Ann L. Wirtz, Douglas Swanson, Rachel Moran, Jessica Peters, Christine Symes, Liset Olarte, Rana El Feghaly

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Introduction: Pneumococcal disease causes significant morbidity and mortality in children. Routine childhood immunizations protect for 13 or 15 pneumococcal serotypes via two pneumococcal conjugated vaccines. Patients with immunocompromising and chronic medical conditions are at high risk of invasive pneumococcal disease. A 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended in these patients to protect against more pneumococcal serotypes, but many patients have not received it. Our AIM is to increase PPSV23 vaccination rates among eligible patients in both the inpatient and outpatient infectious diseases (ID) settings from a baseline of 44% to 55% by October 2024. Methods: In collaboration with Children’s …

The Implementation Of A Pectus Bar Insertion Eras Pathway, Todd A. Glenski, Emily Weisberg, Christian M. Taylor, Brandon Layton, Andrea Melanson, Sameer Lalani

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No abstract provided.

Candida Chorioretinitis In Immunocompromised Patient With Candida Tropicalis Fungemia Secondary To Chemotherapy, Jourdan Valkner Krause

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Summary: An immunocompromised patient with candida tropicalis fungemia secondary to chemotherapy presented for follow up of candida chorioretinitis. This infection puts the patient at high risk for CNVM formation and must be followed closely. Case History: • 3-year-old Hispanic female • CC: Candida chorioretinitis follow up • POH: Bilateral orbital chloromas and optic nerve atrophy • PMH: Acute myeloid leukemia, Candida tropicalis fungemia • Meds: o Amphotericin B liposomal 85 mg 42.5 mL, IV, q24hr o Flucytosine 500 mg Capsule *NF* 1,000 mg 2 capsule, PO/NG, q6hr o Micafungin 100 mg 100 mL, IV, q24hr *Plus numerous chemotherapy, pain and …

Teaching And Tomorrow: Children's Mercy Hospital Pediatric Gastroenterology Fellowship Program, Children's Mercy Kansas City

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No abstract provided.

Anesthetic Management Of Clamshell Thoracotomy For Large Tumor, Kasey Brooks, Nathaniel Lata

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No abstract provided.

Impact Of Fetal Health Center On Mode Of Neonatal Death, Erin Bolen, Ashley Sherman, Julie Weiner, Jotishna Sharma

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Introduction There has been significant innovation and technological advancement in prenatal diagnosis, fetal therapeutic intervention, and establishment of fetal health centers (FHC) at children’s hospitals with dedicated delivery services for high-risk neonates and expedited access to level IV neonatal intensive care units (NICU). Morality trends have been examined on individual bases and within diagnostic groups, but there have been few studies that examine overall modes of mortality in the NICU population across diagnoses after the implementation of a dedicated FHC. This study aims to compare modes of death at a level IV children’s hospital NICU between infants born at the …

Latency Time From Prior Authorization Submission To Initiation Of Biologic Therapy In Inflammatory Bowel Disease, Shannon Capraro, Janelle R. Noel-Macdonnell Phd, Lauren Disselhoff, Layne Sieve, Rachel Chevalier

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Background For pediatric patients with a diagnosis of inflammatory bowel disease (IBD), initiation of biologic therapy can be essential to attain disease control. Unfortunately, patients often experience delays in receiving the first dose of these medications due to the need for insurance companies to approve medication prior authorizations (PA). Physicians and support staff spend many working hours collating and transferring information regarding urgency to payors. To our knowledge, no studies exist to evaluate the factors that contribute to how quickly a medication is approved in pediatric patients. We set out here to evaluate which demographic and disease factors contribute to …

Life Threatening Anemia And Acidosis Secondary To Systemic Loxoscelism In A Pediatric Patient, Rohan Akhouri, Vincent J. Calleo, Leslie Hueschen

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Introduction Rashes are common in pediatric patients and most resolve without significant patient illness. In rare cases, they can represent life-threatening disease entities. History is crucial to determine a rash’s etiology, and barriers like developmental delay and language can complicate accurate diagnosis. We present a case of hemodynamic instability and hemolysis without known envenomation, which was diagnosed as systemic loxoscelism. Case Description A 10-year-old male with developmental delay presented with decreased activity and reduced oral intake for 4 days. An interpreter was used due to a language barrier. Initial vital signs were T 36.6°C, HR=120, RR=20, BP=117/66, and SpO2 96%. …

National Prescribing Practices For Dystonia Among Providers In The United States, Sarah Paige Davis, Natalie J. Kane, Haley Botteron, Rose N. Gelineau-Morel

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Objective: While multiple oral medications are used to treat dystonia, limited information exists on current prescribing practices. This study analyzes prescribing practices for dystonia in the United States, evaluating variations in dosing and impact of co-morbidities. Methods: Querying the Cerner Real World database from 2014 to 2019 for children age 0-18 with an ICD-10 diagnosis containing “dystonia” resulted in 11,300 inpatient and outpatient encounters. Information extracted included current dystonia medications (baclofen, clonidine, carbidopa-levodopa, gabapentin, tetrabenazine, trihexyphenidyl, and benzodiazepines including diazepam, clonazepam, midazolam, and lorazepam), medication dosing, and co-morbid diagnoses of cerebral palsy, epilepsy, or spasticity. Encounters without current weight were …

Exploring Bidirectionality In Us Pediatric Global Health Programs, Anik Patel, Pauline Kamau, Ashley Combs, Megan Mchenry

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Introduction: Over the last two decades, GH programs have offered experiences at partner sites through established global health partnerships (GHPs). Historically, GHPs have been one-directional, favoring partners from resource-rich settings. These partnerships are now being reevaluated through the lens of equity and decolonization. We seek to understand how US pediatric GH faculty define the concept of “bidirectionality”, assess perspectives on their institution’s practice of bidirectional activities, and explore perceived benefits and challenges to prioritizing bidirectionality within their own GHPs. Methods: This is a cross-sectional qualitative survey study on bidirectionality of 206 AAMC-accredited US pediatric residency programs. 24 survey responses from …

A Genomics Driven Pluripotent Stem Cell Model Of Infant Acute Lymphoblastic Leukemia, Meagan Vacek, Jacqelyn Nemechek, Julia Draper, Irina Pushel, Bradley Thornton, Molly Leyda, Priyanka Prem Kumar, Midhat S. Farooqi, Jay L. Vivian, Erin M. Guest, John M. Perry

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Acute lymphoblastic leukemia in infants (iALL) is a high-risk subtype of childhood leukemia, with poor survival outcomes despite intensive therapies. Rearrangement of KMT2A (KMT2A-r) on chromosome 11q23 is the most frequent cytogenetic abnormality in iALL, occurring in 70% of cases. KMT2A-r is associated with chemotherapy resistance, early relapse, and rapid leukemic progression, all of which contribute to poor survival outcomes. The most common KMT2A-r in iALL is KMT2A::AFF1 (MLL::AF4), derived from t(4;11)(q21;23) and arises in utero as shown in multiple clinical studies. Infant ALL’s cell of origin is thought to be a very early hematopoietic precursor, with transcriptomic studies of …

Rare Complications Associated With Use Of Bovine Pericardium, Mohamed Aashiq Abdul Ghayum, Nitin Madan, William Gibson, Sanket Shah

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Background Bovine Pericardium (BP), with numerous and improving preparation techniques, has been used extensively for over 50 years in repair of simple and complex congenital heart defects. It has several advantages over other surgical materials. However, there is a paucity of data in the pediatric population regarding complications associated with BP. Herein, we report two rare complications noted with BP use. Case Description Case 1. A 14-month-old male, with trisomy 21 and complete Atrioventricular canal defect, repaired using BP. A routine surveillance echocardiogram showed a mass attached to the atrial septum and atrial aspect of the left atrioventricular valve (Figure …

“It's So Expensive And Isn’T Any Better! Or Is It?” A Comparative Analysis Of Price Per Ecmo Hour, Intracranial Hemorrhage, And Survival Rates In Neonates On Bivalirudin Vs. Heparin, Johanna I. Orrick, Jessie Charbonneau, Kari L. Davidson, Alexandra Oschman, John M. Daniel Iv

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Background: Heparin has been the anticoagulant of choice for Neonatal ECMO for the past thirty years. It has the benefit of being well studied and having a low production cost. As bivalirudin is a newer anticoagulant, it has not been as widely studied and has a higher production cost, many centers are concerned about changing to a newer, more expensive agent. Bivalirudin has been studied from both an efficacy and cost perspective in adult patients (Sun et al 2021) and pediatric VAD populations (Burnstein et al 2023). While some safety and efficacy data exist for neonates, there are few if …

Ecmo Clinical Practice Committee: Empowering The Frontline Staff, Michelle Mckain, Shayna Evans, Johanna I. Orrick, Kari L. Davidson

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Background: Extracorporeal Membrane Oxygenation (ECMO) is a complex artificial life support for patients with severe respiratory and cardiac failure. Children’s Mercy was an early ECMO pioneer, establishing a program in 1987. Despite CM’s successful history, wide variations existed between regional management of ECMO (Schwartz et al., 2022). Studies show that patient outcomes, resources, staff satisfaction, and financial metrics improve with implementation of an interprofessional shared governance team (Olender et al., 2019; Schwartz et al., 2022). In 2016, the ECMO Clinical Practice Committee (ECP) was created, tasked with addressing projects aimed at ECMO process improvements. Methods: ECP members include Registered Nurses …

Standard Atrial Epicardial Wire Placement Leads To Improved Atrial Signal Identification And Pacemaker Sensing, Nir Atlas, William Gibson, J Hermsen, A Harmon, J Torgeson, Lindsey Malloy-Walton, N Von Bergen

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Background: Atrial arrhythmias are common after pediatric cardiac surgery and are associated with increased morbidity and mortality. Atrial epicardial wires (AEW), utilized to diagnose and treat atrial arrhythmias, are known to malfunction during post-operative care. There are no pediatric prospective studies examining ideal placement of AEW. Methods: This prospective multicenter pilot study compared atrial amplitudes, pacing sensitivities and thresholds via AEW placed at Bachmann’s Bundle (BB) and the right-sided interatrial groove (RSIG) versus the surgeon’s standard placement (control locations) in 26 patients aged less than six years old undergoing cardiac surgery. Participants received four total AEW - two at the …

Treatment Of Post-Operative Pain In Children With Severe Neurologic Impairment, Jordan Keys, Jessica L. Bettenhausen, Jessica L. Markham, Matthew Hall

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Introduction The assessment of pain in children with severe neurologic impairment (SNI) can be more challenging than in neurotypical children. Objective To describe: 1) the type, number of classes, and duration of post-operative pain medications for common procedures among children with SNI and 2) the variability in pain management strategies across children's hospitals, specifically for opioid administration. Methods This retrospective cohort study, using the Pediatric Health Information System database, included children aged 0-21 years hospitalized with SNI who underwent common procedures during 2019. We defined SNI using previously described high-intensity neurologic impairment (HINI) diagnosis codes and identified six common ( …

Development Of A Kineisophobia Scale For Adolescents With Heart Disease: A Preliminary Analysis Of Validity And Reliability, David A. White, Jami Gross-Toalson, Emily Cramer, Lindsey Malloy-Walton, Mollie Walton, Laura Martis, Brandy Enneking, Kelli M. Teson, Jessica S. Watson, Dara Watkins, William R. Black

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No abstract provided.

Delirium On Admission To The Cicu, Spencer Wittmeyer, Jaime Silva-Gburek, Kelly S. Tieves

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Background: Delirium is increasingly recognized in the pediatric cardiac intensive care unit (CICU) with an incidence up to 67% and is associated with worse outcomes including increased mortality, prolonged hospitalization, and increased rates of intubation and mechanical circulatory support. The Cornell Assessment for Pediatric Delirium (CAPD) is the only validated tool for the diagnosis of delirium in the pediatric population. The CAPD may be limited in children with developmental disabilities as it does not account for baseline ability in scoring. Prior work has identified low specificity for the CAPD in children with developmental disabilities and those requiring mechanical ventilation. This …

Identification Of Critical Illness-Related Corticosteroid Insufficiency After Congenital Heart Surgery With Next Generation Sequencing, Juan S. Farias, Nicholas Diehl, Lori A. Erickson, Jenny Marshall, Nataliya Kibiryeva, Kelly S. Tieves, Jorge Cross-Bu, Jaime Silva-Gburek

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Introduction: Critical illness-related corticosteroid insufficiency (CIRCI) which is characterized by relative inadequate cortisol levels in relation to increased demand during periods of severe stress is common after cardiac surgery and is a cause of hemodynamic instability. The purpose of this study was to identify possible genetic abnormalities related to CIRCI in pediatric patients after congenital heart surgery. Methods: Single-center retrospective study of neonates who underwent cardiac surgery between August 2018 to July 2020. We included patients who had obtained postoperative cortisol levels and next gen DNA-sequencing (NGS) as previous standard of care. Analysis methods are displayed in Figure 1. Results: …

An Unusual Cardiomegaly Culprit: Case Report Of A Hemodynamically Significant Portosystemic Shunt, Zoetta L. Mcloughlin Md, Melanie Kathol, Amanda Mcintosh

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Background: Cardiomegaly discovered in the fetal or neonatal period may be the first sign of cardiac disease. However, the differential diagnosis for cardiomegaly with a structurally and functionally normal heart includes cardiomyopathies as well as non-cardiac etiologies, including extracardiac shunt lesions and vascular malformations, among others. Thus, unexplained cardiomegaly requires further investigation for extracardiac anomalies. In this case, we focus on an unusual etiology of diffuse cardiac dilatation – intrahepatic portosystemic shunt – that was initially misdiagnosed as dilated cardiomyopathy. Case Description: A 9-year-old male with history of learning difficulty and tall stature was seen for follow-up of diffuse cardiomegaly …

Multi-Disciplinary Collaboration And The Use Of Technology In The Reduction Of Cardiac Surgical Site Infections, Kelly Fehlhafer, Tiffany Mullen, Elizabeth Chang, Stacy Reynolds, Shannon Lysaught, Stephanie Doughty, Jessica Nichols

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No abstract provided.

Predictive Value Of Syntax Ii Score In Patient With Acute Myocardial Infarction Complicated By Cardiogenic Shock: A Healthcare Network Based Study, Md Mashiul Alam, Sun-Joo Jang, Mohamed A. Badheeb, Mary Quien, Ju Young Bae, Ashraf Ahmed, Mark Samsky Md, Michael Nanna Md, Elliot Miller Md, Carlos D. Davila

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The SYNTAX II score was designed to improve decision making between CABG and PCI.

Clinical correlation of SYNTAX II score in patients with AMI complicated by cardiogenic shock (AMI-CS) is investigated

Prevalence Of Iron Deficiency In Patients With Inherited Bleeding Disorders, Thomas Cochran, Brian R. Lee, Shannon L. Carpenter

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Background: Patients with bleeding disorders have greater propensity for blood loss and therefore may have a higher prevalence of iron deficiency (ID) when compared to the general population. However, current literature focuses on adolescent females and few studies have assessed the overall prevalence of ID in children with inherited bleeding disorders. Aims: This study aims to identify the prevalence of ID in children with an inherited bleeding disorder. Methods: A retrospective analysis of children with any inherited bleeding disorder seen in Children’s Mercy Hospital’s Hemophilia Treatment Center between 2010 and 2020 was performed. Iron deficiency was defined by recently published …

Central Hypothyroidism Following Neonatal Graves' Presentation, Emily Metzinger, Kelsee Halpin

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Background: Neonatal Graves’ disease is a rare disorder of neonatal autoimmune hyperthyroidism secondary to the transplacental passage of thyroid-stimulating hormone receptor antibodies. Although neonatal Graves’ disease is transient, it is associated with cardiac dysfunction, intrauterine growth restriction, prematurity, craniosynostosis, and developmental delay and can be life-threatening. Additionally, infants with neonatal Graves’ disease can rarely present with primary or central hypothyroidism later in infancy or childhood. This is suspected to be due to the disruption in the hypothalamic-pituitary-thyroid axis or development of the thyroid gland. Clinical Case: Here we describe a case of neonatal Graves’ disease that has been complicated by …

Supporting Fathers And Partners In The Nicu, Tiffany Gladdis

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The NICU can be an incredibly stressful environment for both the infant and its parents. Unlike many traumatic events, the NICU experience can often feel like an ongoing trauma, with the stay often involving highs and lows, new diagnoses, changes in prognosis, multiple procedures, and a rollercoaster of emotions. Additionally, the NICU can also trigger trauma responses for parents who have had previous traumatic experiences. When working with families in the NICU, it is important to use a Trauma Informed Care lens to ensure that the whole family is understood and adequately supported (Sanders & Hall, 2007). Perinatal Mood and …

Failed Medial Column Fusion Due To Subtalar Joint Instability, Travis Rich, Randy Semma, Michele Bertelle-Semma

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• CNA is a destructive complication affecting the bone and joint structure, most often in diabetics w/ longstanding peripheral neuropathy.
• High incidence of major amputation associated with Charcot foot

Utilization Of Negative Pressure Wound Therapy And Split Thickness Skin Grafts In The Context Of Complex Skin Closure Via Secondary Intention: A Protocol Approach, Jihan Toma, Eric Li, Randy Semma, Michele L. Bertelle-Semma, Asif Khan

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Patients with complex, chronic foot wounds or ulcerations are at risk for major amputations. In this quality improvement (QI) initiative, we present an implemented protocol for patients with foot ulcerations and attempt to heal them using a combination of wound vac therapy and split thickness skin grafting. These patients have a history of either diabetes and/or neuropathy that makes wound healing more difficult than an otherwise healthy individua

Diabetic Limb Salvage: Chopart Amputation, Jesse Miller, Randy Semma

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Diabetic limb salvage is the act of saving a limb, even with decreased function after infection.

It is the difficult choice of the surgeon/patient to decide to proceed with salvage versus amputation proximally.

Case Report Of Bullous Diabeticorum: A Self-Limiting Condition With Potentially Devastating Consequences, Taylor Allison, Randy Semma

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Bullous diabeticorum (BD) is a skin manifestation of patients with diabetes mellitus with an incidence of about 0.16% per year (Larsen et al) although the condition is believed to be widely underdiagnosed. The blistering disease favors acral regions of the body including the feet. There are no accepted diagnostic tests, and histopathology results are often inconclusive which makes BD a clinical diagnosis of exclusion. It is often self-limiting and resolves in a few weeks without residual sequelae. However, it may present with a secondary bacterial infection which can put patients at risk for soft tissue infections and osteomyelitis requiring more …

Revisional Arthrodesis Of Tarsometatarsal (Lisfranc) Complex Injury Secondary To Non-Union, Lei Wilson, Randy Semma

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The tarsometatarsal joint and its components provide structural support for the foot. Notably the Lisfranc ligament is a fundamental stabilizer for the midfoot. Injuries to this component are complex and can be debilitating. These injuries require surgical intervention when significant displacement resulting in instability is involved.

Following success of several previous repairs of Lisfranc fractures and dislocations, a treatment algorithm has been proposed. This case report demonstrates the success of the algorithm which has allowed the surgeon to perform reduction and repair in a reproducible, step-wise manner with minimal difficulty to ensure successional revisional arthrodesis of a nonunion