Medical Specialties Commons^™

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 …

Case Series: Bone Marrow Failure In Teen Siblings With Unique Rps19 Variant, Alexandra Prosser

Research Days

Background: Upon diagnosis of aplastic anemia, inherited bone marrow failure syndromes and acquired etiologies must be considered. Investigating causality is particularly important when multiple family members are affected. It is also essential to identify novel causative genetic variants of bone marrow failure to direct treatment in these patients.

Objectives: To describe the diagnosis and management of siblings who presented two weeks apart with severe pancytopenia and were diagnosed with severe aplastic anemia.

Methods: The first patient is a 13-year-old non-binary female who presented with severe pancytopenia on routine labs. Bone marrow biopsy revealed marked hypocellularity (0-10%) with hypoplasia. The second …

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

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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 …

Variation In Laboratory & Radiographic Workup And Outcome In Children Hospitalized With Common Musculoskeletal Infections, Emily Bonanni

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Background: Common pediatric musculoskeletal infections (MSKIs) require prompt recognition & treatment to prevent significant morbidity and mortality. Variation in initial workup of these infections & associations with clinical outcomes is not well studied and could aid development of evidence-based guidelines to provide high-value care for all MSKIs.

Objectives/Goal: Examine variation in initial lab testing & imaging obtained in patients hospitalized for common MSKIs and explore association with clinical outcomes (length of stay (LOS), cost, 30-day readmission).

Methods/Design: We performed a retrospective, multicenter cohort study of hospitalized children aged 6 months to 18 years with a …

Financial Outcomes By Severity Across Children's Hospitals, Jonathan Hartley

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Background: Hospitalizations represent a significant driver of healthcare costs for children. Little is known about how payor type and the severity of children cared for on the pediatric medical inpatient floor impact a hospital’s financial outcomes.

Objectives/Goal: The primary objective of this study is to compare financial outcomes of pediatric hospitalizations to the medical inpatient floor across patient severity quartiles. Secondary objectives included financial outcomes stratified by payor type across severity quartiles.

Methods/Design: Retrospective cohort study included children aged 0-18 years discharged during calendar year 2019 from hospitals that reported clinical information to the Pediatric …

Spending On Public Benefit Programs And Exposure To Adverse Childhood Experiences, Megan Collins

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Background: Adverse childhood experiences (ACEs) have been shown to be associated with poor health outcomes, and children living in poverty are more likely to experience ACEs. Our objective was to estimate the association between spending on benefit programs and cumulative exposure to ACEs among children.

Methods: This cross-sectional study examined state and federal spending, at the state-level, on 5 categories of public benefit programs: cash, housing, and in-kind assistance; housing infrastructure; childcare assistance; refundable Earned Income Tax Credit; and Medical Assistance Programs (e.g., Medicaid). The primary exposure was median annual spending per person living below …

Everyday Ethics And Equity At The Bedside, Shika Kalevor, Angie Knackstedt

Research Days

Background: Traditional bioethics training, although important, may not be completely suited to the nursing role. In contrast to traditional clinical ethics, which focuses on healthcare dilemmas, everyday ethics focuses on routine clinical encounters between clinicians, patients, and families and may be better suited to help nurses address issues such as bias and racism at the bedside.

Objectives/Goal: This study aims to provide a data-backed approach to ethics education for nurses as it pertains to improvements in the understanding of Diversity, Equity, & Inclusion (DEI) efforts in healthcare. This study also provides an opportunity for the field of bioethics to provide …

Barriers And Facilitators To Precision Medicine For Black Children With Autism Spectrum Disorder, Rachel Goodson

Research Days

Background: The field of pharmacogenomics (identification of biomarkers regarding drug metabolism and activity to inform precision prescribing) is rapidly advancing for individuals on the autism spectrum, but these advancements are not equitably benefiting all communities. Specifically, utilization data suggests that Black families may be less likely to have access to clinical precision medicine supports. Moreover, historic underrepresentation of African-descended populations in genetic reference samples means that emerging research on precision medicine will retain these biases and perpetuate disparities in downstream clinical benefit. These issues are especially relevant to the autism community, who are more likely to receive psychotropic medications that …

Likelihood Ratios For Reactions To Egg Based On Specific Ige And Oral Challenges, Melissa Anderson

Research Days

Background: Specific IgE (sIgE) to foods has been used to predict the risk of a systemic reaction (SR) when the food is ingested. An arbitrary cutoff of 0.35 is often used to separate a positive likelihood ratio (LR+) from a negative one (LR-), yet there is little evidence supporting the use of this value.

Objectives/Goal: The objective of this project was to establish a more accurate method for estimating the probability of food allergy to egg.

Methods/Design: Egg-sIgEs were measured and open oral egg challenges were performed on 155 children with a clinical history of egg allergy. Logistic regression (LR) …

Timing Of Testing For Ige-Mediated Food Allergy After Systemic Reaction, Jordan Pitt

Research Days

Background: A refractory period of falsely negative testing can occur following a systemic allergic reaction to Hymenoptera sting. As a result, blood specific IgE and/or skin prick tests (SPT) for other allergens are often delayed.

Objectives/Goal: This study aims to identify the proportion of patients with falsely negative test results in the 6 weeks following an allergic reaction to food, and factors that may affect it.

Methods/Design: This is a retrospective chart review study. One hundred fourteen pediatric subjects met inclusion criteria. Each had a convincing history of food allergy with a systemic allergic reaction and was tested to the …

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 …

Who Is My Child’S Main Doctor? Assessing Caregiver Perceptions Of Teaching Teams At A Pediatric Tertiary Care Center., Jonathan Ermer

Research Days

Background: The size and structure of large academic teaching teams can create a barrier to communication and relationship-building with caregivers. Studies have shown that from a patient perspective, being able to name their doctor and identify their role is important. Benefits include increased patient satisfaction, improved relationships in line with the family-centered care movement, and improved patient safety. Although important, studies in both adults and pediatrics have shown that patients and caregivers do not know who their doctors are. Acknowledging the hierarchy present on family-centered rounds is not only burdensome and confusing to patients and caregivers, but it can also …

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 …

Feeding And Swallowing Disorders In 100 Children With 22q11.2 Syndrome, Jana Ghulmiyyah

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Background: 22q11.2 deletion syndrome (22q11DS) is the most common microdeletion syndrome. The syndrome includes a wide range of variable features including congenital heart disease, palatal abnormalities, immune deficiency and learning difficulties. Otolaryngologic manifestations include hearing loss, characteristic facial features and laryngotracheal abnormalities. A few studies have reported dysphagia as a common feature of this syndrome however little is known about the specific feeding and swallowing difficulties that occur in children with 22q11DS.

Objectives/Goal: The aim of the study is to identify the frequency of feeding and swallowing disorders in a large cohort of pediatric patients …

Evaluation Of A Modified Pre-Medication Algorithm For Non-Emergent Intubation In A Neonatal Intensive Care Unit, Lilah Melzer

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Background: The use of pre-medication for elective non-emergent intubation in neonates and infants has been suggested to minimize physiologic instability, decrease oral/pharyngeal trauma and decrease time and attempts to successful intubation. A pre-medication algorithm including the use of Fentanyl + Atropine was modified to include a higher dose of fentanyl with addition of muscle relaxant and benzodiazepine in a level IV neonatal intensive care unit.

Objective: The objective of this study was to compare first attempt success of intubation pre- vs post-modification of the pre-medication algorithm.

Methods: This is a single site retrospective chart review. …

Inpatient Outcomes For Children Receiving Empiric Methicillin-Resistant Staphylococcus Aureus Coverage For Complicated Pneumonia, Sophia Hackman

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Background: Pediatric community acquired pneumonia is responsible for an estimated 124,000 hospitalizations annually in the United States, with up to 40% of hospitalized children subsequently developing a complicated pneumonia (i.e., effusion/empyema). Children with complicated pneumonia commonly require increased numbers of procedures, have exposure to broad-spectrum antibiotics, and have prolonged hospitalizations. While the prevalence of pneumonia has overall declined with childhood vaccination, the number of children with complicated pneumonia has remained stable. Current guidelines do not adequately address antibiotic management of pediatric complicated pneumonia specifically when to utilize methicillin-resistant Staphylococcus aureus (MRSA) coverage, likely contributing to …

Improving Antibiotic Durations For Skin And Soft Tissue Infections In Pediatric Urgent Care Clinics, Megan Hamner

Research Days

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Problem Statement/Question: Although national guidelines recommend 5-7 days of oral antibiotics for most skin and soft tissue infections (SSTIs), in 2019, CMH urgent care clinics (UCCs) prescribed > 7-day courses for 42% of patients diagnosed with SSTIs. Prolonged antibiotic courses result in increased patient burden, cost and adverse events which could be prevented by prescribing shorter courses.

Background/Project Intent (Aim Statement): To increase the percentage of patients receiving 5- 7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021, in CMH UCCs.

Methods (include PDSA cycles): We formed a multidisciplinary team …

A Novel Approach To Triosephosphate Isomerase Deficiency, Kyra Mccarty

Research Days

Background: Triosephosphate isomerase deficiency (TPID) is a glycolytic pathway enzymopathy causing hemolytic anemia and neurologic dysfunction. TPID is caused by mutations in the TPI1 gene. These patients experience severe hemolytic anemia in infancy followed by progressive neurodegeneration. Diagnosis of TPID is made by measuring decreased TPI enzyme activity elevated dihydroxyacetone phosphate (DHAP) levels in the blood. The diagnosis is confirmed by molecular genetic testing. Neurological involvement typically manifests between 6 and 24 months of age, causing progressive motor dysfunction. Chronic axonal neuropathy is often present on nerve biopsy, and peripheral neuropathy is evident on electrophysiologic studies. Splenectomy and blood transfusions …

Supraclavicular Neck Mass In A 14 Month Old Boy, Jana Ghulmiyyah

Research Days

Background: Lipoblastoma is a rare benign tumor arising from embryonic fat cells in children younger than 3 years of age. They rarely present in the neck and usually do not have spindle cell appearance. We therefore present a case of neck lipoblastoma with review of the literature.

Case Description: We present the case of a 14-month-old male who presented with 1 month history of a right supraclavicular neck mass that was enlarging gradually. On physical exam, it was non tender, mobile with no overlying skin changes. Patient did not have any respiratory distress. A fine needle aspirate (FNA) showed spindle …

Diagnostic Features And Clinical Outcomes Of Children With Tubulointerstitial Nephritis And Uveitis Syndrome (Tinu), Christian Oliveros

Research Days

Background: Tubulointerstitial nephritis and uveitis (TINU) syndrome is an inflammatory disease that affects the kidneys and eyes. TINU is rare, but likely under-recognized due to variable clinical presentation, nonspecific symptoms, and lack of universally accepted diagnostic criteria. The optimal treatment approach in children with TINU remains unknown.

Objectives/Goal: The purpose of this case series is to contribute further knowledge to this rare disease by describing disease features and treatment response of patients with TINU treated at a single center.

Methods/Design: A retrospective chart review was performed of children diagnosed with TINU at a single tertiary care children’s hospital since January …

Primary Venous Thromboprophylaxis In Pediatric Oncology Patients, Kyra Mccarty

Research Days

Background: The Virchow’s Triad principles of venous stasis, endothelial damage, and hypercoagulability are all features of malignancy and contribute to the increased risk venous thromboembolism (VTE) seen in oncology patients. Additionally, certain chemotherapy treatments, presence of a central venous catheter and immobility are also intrinsically associated with malignancy diagnoses and exacerbate this risk. However, much debate exists over the use of thromboprophylaxis in the pediatric population, primarily due to lack of evidence regarding safety and efficacy, primarily the risk of major bleeding. Multiple retrospective studies have attempted to identify the primary risk factors for VTE in this pediatric oncology patient …

Development Of Medical Alert Cards Using Structured Data To Assist In The Management Of Children With Anorectal Malformation, Cloaca, And Cloacal Exstrophy, Ninad Prasade

Research Days

Introduction: Anorectal malformations (ARM), including cloaca and cloacal exstrophy, are a rare collection of congenital disorders of the distal hindgut resulting in lifelong anatomic and functional impairments. Children with ARM may often have other congenital anomalies in the VACTERL association (vertebral, anorectal, cardiac, tracheoesophageal fistula, renal, limb), leading to anatomic variations and prior surgeries that require consideration in diagnosis and management. Patients with these conditions may have multiple presentations to the healthcare system. Understanding emergencies specific to these conditions can enable patients' families and providers to quickly recognize important anatomic variations and initiate care management.

Aim: Our study aimed to …

Identify Factors Associated With Excessive Corneal Haze Noted To Have Increased In Frequency Over The Last 6 Months Post Corneal Cross-Linking Procedure, Sonal Dangda

Research Days

Problem Statement/Question: Over the past 6 months, increased post-operative corneal haze and decreased vision was noted in patients following corneal crosslinking for keratoconus.

Background/Project Intent (Aim Statement): Identify factors that may contribute to increased postprocedure haze and analyze these factors for the total cohort of crosslinking patients since 2017. The goal of this study is to ensure that the increased haze is due to unique patient factors and not an external cause.

Methods (include PDSA cycles): Patients who underwent corneal cross-linking between January 2017 – December 2021 were identified. Retrospective data was collected at baseline visit, at one-month postcrosslinking and …