Medical Specialties Commons^™

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 …

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 …

Automating A Well Child Visit, Daniel Merrill

Research Days

No abstract provided.

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 …

Initiating Coordination Of Care For Children In State Custody Or Shelter Care, Angela Doswell

Research Days

Problem Statement/Question: Children in the foster care system experience barriers to continuity of care, both in the primary and subspecialty outpatient settings.

Background/Project Intent (Aim Statement): To decrease average percentage of scheduled but missed specialty appointments whose initial referrals were placed in the Foundations Foster Care Clinic (FCC) from 40% to 20% over a 10- month period from March-December 2020.

Methods (include PDSA cycles): Referrals to specialty clinics were placed during an initial or follow-up visit in the Foundations Foster Care Clinic (FCC). One PDSA cycle was performed and involved notification of the patient’s case worker when a referral was …

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 …

Improving Transition To Adult Care Discussion In A Diabetes Clinic, Erica Wee, Erica Zarse, Lindsay Baldridge

Research Days

Problem Statement: Diabetes mellitus is a chronic condition requiring complex care. Adolescents with diabetes face challenges when transitioning to an adult care setting which can lead to suboptimal glycemic control and emergence of complications. It is important for a pediatric diabetes clinic to provide support and prepare adolescents for success when they transfer to adult care.

Aim Statement: In our diabetes clinic, patients are eligible for transition assessment if they are over age 17 years without a documented discussion in the past 1 year. A review of clinic data between October 2021 and November 2021 revealed that an average of …

Outcomes Of A Quality Improvement Project: Implementing Trauma Informed Care In A Neonatal Intensive Care Unit, Jennie Godwin

Research Days

Problem Statement/Question: Will providing Trauma Informed Care (TIC) education to physicians in a large Level IV NICU increase their uptake and implementation of TIC practices?

Background/Project Intent (Aim Statement): The experience of being hospitalized in a Neonatal Intensive Care Unit (NICU) is recognized as a traumatic stressor to both the infants and their families. Physicians working in the NICU experience indirect traumatization and are at risk for burnout. Trauma Informed Care (TIC) can increase effectiveness of healthcare delivery, ensure that staff, policies and procedures do not cause unintentional harm, promote staff resilience, and improve the overall quality of the patient …

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 …

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 …

Nasal Chondromesenchymal Hamartoma: A Case Report And Review Of The Literature, Jana Ghulmiyyah

Research Days

Background: Nasal chondromesenchymal hamartoma (NCMH) is a rare benign tumor of the sinonasal cavity. It commonly presents in infancy, however there are reported cases of adult tumors. As of August 2021, there have been 56 reported cases in the literature. This is the first description of a solely endoscopically resected NCMH in a neonate in addition to a review of the literature.

Case Presentation: A 5-day old male patient born at term presented to our institution for stridor and cyanosis since birth. The patient was reported to have desaturations while feeding at the outside hospital. On bedside examination, the patient …

Diagnosis, Management, And Treatment Of Lymphadenitis And Deep Neck Space Infections At A Children’S Hospital, Aaron Shaw

Research Days

Background: Although cervical lymphadenitis and deep neck space abscesses (DNSA) are relatively common pediatric diagnoses, no standardized approach exists for management of these infections.

Objectives/Goal: To assess variability in diagnosis and treatment of cervical lymphadenitis and DNSA in a children’s hospital.

Methods/Design: Charts were obtained using ICD9/10 codes for diagnoses of retropharyngeal and parapharyngeal abscess, and lymphadenitis between 1/1/10-12/31/20. 1,237 charts were identified. Patients with a retropharyngeal and/or parapharyngeal abscess were defined as DNSA. Charts were excluded if the diagnosis was not a bacterial infection (e.g. Kawasaki disease), if the lymphadenitis was not in the neck, or if caused by …

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 …

Large Single Center Experience In Pediatric Oncology And Bone Marrow Transplant Patients On Ecmo: How Should We Decide Candidacy?, Jordan Marquess

Research Days

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Background: ECMO is rarely utilized in pediatric oncology and bone marrow transplant (BMT) populations due to concerns surrounding poor prognoses and high rates of complications. Patients with malignancies are often not offered ECMO as an option. There is paucity of data to determine whether a pediatric oncology or bone marrow transplant patient is an appropriate candidate for ECMO.

Methods: This is a single center retrospective cohort study on pediatric patients with primary oncologic diagnosis or history of bone marrow transplant who required VA- or VV-ECMO from 2015-2020.

Results: Twelve patients were identified with a 58% …

Admission Pao2 And Mortality Among Pediatric Icu Patients And Critically Ill Subgroups, Cara Holton

Research Days

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Background and Objectives: Studies analyzing the association between hyperoxia and mortality in critically ill pediatric patients and those admitted after cardiac arrest are conflicting and limited by small sample sizes. The aim of this study is to evaluate the association between PaO2 on admission to the pediatric ICU and mortality in a heterogeneous, multicenter cohort and among subgroups of critically ill patients.

Methods/Design: A retrospective cohort study was conducted using data from Virtual Pediatric Systems (VPS) database. VPS is a clinical pediatric critical care database with over 135 participating hospitals in North America. All VPS …

Safety, Timing And Outcomes Of Early Postoperative Cardiac Catheterization Following Congenital Heart Surgery, Karoline Krzywda

Research Days

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Background: Early postoperative ( < 6weeks) cardiac catheterization (EPOCC) has been considered high risk and often delayed. Recently, the safety of EPOCC has been demonstrated. The optimal timing of catheterization and its outcomes in struggling postoperative patients remains uncertain.

Objective: To describe EPOCC in our center and its impact on length of stay (LOS), number of mechanical ventilation days, number of ECMO days, and catheter-based interventions.

Methods: This is a retrospective cohort study of patients who underwent cardiac surgery between 01/01/2010 and 12/31/2019 and EPOCC within 30 days after surgery. Cohorts were early EPOCC (≤72 hr) vs late EPOCC ( >72 hr). Data on timing, indication, and complications of EPOCC; days of mechanical ventilation and ECMO; and CICU/total hospital LOS were collected. Data was analyzed using chi-square and Student’s t-test, …

Ekg Technology: It Is Time For A Change!, Megan Carroll

Research Days

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Background: Technology for obtaining pediatric EKGs has not changed in over 70 years. Current guidelines recommend a 12-lead EKG, which takes approximately 7 minutes to complete. Newer adult technology utilizes between 1-6 leads for EKG analysis. There has not been a study in pediatrics to assess the minimum number of leads required to attain diagnostic accuracy.

Objectives/Goal: To determine the appropriate number of leads needed to read pediatric EKGs safely and accurately.

Methods/Design: This is a single center systematic review that included randomly selected EKGs from our hospital database (2017-2020) read by two independent pediatric …

Sigirr Variants Identified In Nec Infants Exaggerate Toll-Like Receptor Mediated Inflammation, Jennie Godwin

Research Days

Background: A key event underlying uncontrolled inflammation in necrotizing enterocolitis (NEC) is pathologic activation of Toll-like receptors (TLR). TLR4 recognizes lipopolysaccharide (LPS), from Gramnegative bacteria, and TLR2 peptidoglycans (PAM3Csyk4, PAM), from Gram-positive bacteria. TLR4 and TLR2 signaling events induce an inflammatory cascade through NF-kB, a cytokine inducing transcription factor. Single-immunoglobulin interleukin-1-related receptor (SIGIRR) is a major negative regulator of TLR-mediated NF-kB activation. Previous work from our lab suggests that loss of function in SIGIRR may predispose to NEC. Our lab has identified four variants in NEC patients predicted to alter function of SIGIRR. We hypothesized that identified SIGIRR variants will …

Maternal Antepartum Administration Of Lactoferrin Ameliorates Neonatal Infection By Bacteremia-Producing Escherichia Coli In Mice, Charity Dunlop

Research Days

Background: E. coli is a major cause of neonatal sepsis. Vaginal pathogenic E. coli strains ascend into the pregnant uterus infecting the offspring of colonized mothers. Lactoferrin (LF) is an antibacterial and immunomodulatory glycoprotein that has been given to preterm newborns to prevent lateonset sepsis. However, the effects of maternal LF administration to prevent neonatal E. coli invasive infection have not been studied.

Objectives/Goal: Our goal was to test the hypothesis that LF pre-treatment of pregnant mice administered prenatally will significantly reduce the bacterial load in their embryos following infection with E. coli.

Methods/Design: Human LF 100 mcg/mL or placebo …

Increased Prevalence Of Parenteral Nutrition-Associated Liver Disease In Neonates With Congenital Heart Disease, Yasasvhinie Santharam

Research Days

Background: A life-sustaining therapy, use of total parenteral nutrition (TPN) allows for meeting nutritional needs of low birth weight, premature, or otherwise complex infants with conditions that prevent feeding through the GI tract. However, 40-60% of infants on long-term TPN have been shown to develop parenteral nutrition-associated liver disease (PNALD)1 , a serious condition characterized by cholestatic jaundice, steatosis, and hepatic fibrosis. Given these risks, providers must account for risk of hepatic injury when prescribing TPN, including attributes of gestational age, infection, surgical and diagnosis history2-6 . Yet with a multifactorial pathogenesis, significant heterogeneity in PNALD incidence still occurs. Looking …

Assessment Of Dental Care In Children With Congenital Heart Disease, Mollie Walton

Research Days

Background: The incidence of infective endocarditis (IE) is significantly higher in patients with congenital heart disease (CHD) compared to the general population. Studies have investigated the incidence of IE in adults with CHD to identify the factors that contribute to the development of IE. One such factor is suboptimal oral health. Several studies have shown that children with CHD have higher levels of untreated oral disease as compared to children without CHD.

Objectives/Goal: Identify factors that may affect compliance with routine dental care, including: age, sex, severity of CHD, repair/palliation, and qualification for prophylactic antibiotics.

Methods/Design: A retrospective chart review …

Neonatal Hypoxia Due To Pulmonary Artery Thrombus, Bianca Cherestal

Research Days

Background: Pulmonary artery thrombus is rare and should be considered in neonates with refractory hypoxia.

Case: Preterm female neonate had persistent hypoxia after birth despite intubation, high-frequency oscillatory ventilation (FiO2 100%), and inhaled nitric oxide. Delivery was via c-section at 33 weeks 4 days for new onset hydrops and poor biophysical profile. Echocardiogram revealed echo brightness in the lumen of the left pulmonary artery (LPA) with no color flow (figure 1a), concerning for occlusive thrombus. Chest CT angiogram confirmed the diagnosis (figure 1b, c). Hematology was consulted and recommended systemic thrombolysis (tissue plasminogen activator, tPA) with concomitant anticoagulation (Bivalirudin). Imaging …

Identifying Predictive Factors For Patients Transferred From Floor To Picu Within 24 Hours Of Admission By A Pediatric Critical Care Transport Team, Gina Patel

Research Days

Background: Appropriate triage and disposition during transport can reduce the need for unplanned transfers to the pediatric intensive care unit (PICU) within 24 hours of admission. We sought to determine predictive factors of patients admitted to the inpatient ward that required PICU transfer within 24 hours following transport by Children’s Mercy Critical Care Transport (CMCCT) team. The pediatric early warning score (PEWS) is used to monitor changes in the level of acuity for inpatients at our hospital and has been utilized to measure acuity during transport. We hypothesized patients with respiratory illness and PEWS > 4 during interfacility transport are at …

Association Of Patient Demographics, Code Characteristics, And Survival To Discharge After In-Hospital Cardiac Arrests In The Pediatric Intensive Care Unit, Nathan Lavoy

Research Days

Background: Lower socioeconomic status and minority background have been linked to worse outcomes after out-ofhospital and in-hospital cardiac arrests (IHCA). Despite this, there has not been a focus on IHCA within a pediatric intensive care unit (PICU) evaluating patient demographics and code characteristics.

Objectives/Goal: The primary objective is to describe patient demographics, code characteristics, and survival to discharge of patients that suffer IHCA in a quaternary PICU. The goal of this descriptive, retrospective study is to identify possible differences in outcomes related to patient demographics, laying the foundation for further QI initiatives.

Methods/Design: Participants included patients between 24 hours and …

Prenatal Diagnosis Of Absent Aortic Valve With Continuous Mitral Regurgitation In Turner’S Syndrome: Too Many Things Gone Awry, Amulya Buddhavarapu

Research Days

Background: Congenitally absent aortic valve (AAoV) is a rare anomaly associated with high incidence of perinatal mortality.

Case: A female fetus of twin gestation underwent a fetal echocardiogram at 24 weeks gestation. Findings: rudimentary AoV leaflets with severe aortic insufficiency and aortic arch flow reversal, left ventricular (LV) non-compaction with severe dysfunction. Continuous moderate regurgitation across a dysplastic, functionally atretic mitral valve and borderline restrictive left to right flow through the foramen ovale (FO) was noted, setting for an inverse circular shunt: Aorta - LV- left to right atrium (FO) - right ventricle - pulmonary artery - ductus arteriosus - …

Repeat Tracheal Aspirates In Pediatric Intensive Care Patients: Understanding Clinical Application, Edward Lyon

Research Days

Background: Tracheal aspirate cultures (TA) are regularly obtained in the pediatric intensive care unit (PICU) when clinical changes in intubated or tracheostomy dependent children occur. Positive TA results are often unable to distinguish infection from colonization. There is no data describing the frequency and impact of repeated TAs on patients in the PICU.

Goal: Our objectives were to describe the frequency of repeated TAs in PICU children and emergence of multidrug resistant organisms (MDRO), identify bacterial profile of TAs, and examine antibiotic prescribing patterns related to these cultures.

Methods: A retrospective chart review occurred on 15 patients in the PICU …

The Effects Of Necrotizing Enterocolitis And Short Chain Fatty Acids On The Developing Brain In Mice, Maribel Martinez, Venkatesh Sampath, Paula Nichols, Wei Yu, Suban Burale, Tianhua Lei

Research Days

Background: Necrotizing enterocolitis (NEC) is a devastating disease in premature infants characterized by acute intestinal inflammation and necrosis with a mortality of 15%-30%. Approximately 50% of infants that survive NEC will develop neurodevelopmental defects[1]. Studies on the effects of NEC on the neonatal brain are limited, however it’s postulated that neurodevelopmental damage is induced via cytokine activation of toll-like-receptor 4 (TLR4) by high mobility group box protein 1 (HMGB1) on the microglia Accumulation of reactive oxygen and demyelination contribute to neuronal damage. Therapies that limit the development of NEC can potentially also limit the neuroinflammatory changes seen in NEC[2]. We …

Pharmacometabolomics Profiling Of Preterm Infants Validates Patterns Of Metabolism Associated With Response To Dexamethasone Treatment For Bronchopulmonary Dysplasia, Bradley C. Stockard

Research Days

Background: Bronchopulmonary dysplasia (BPD) is one of the most common health complications of premature birth. Corticosteroids are commonly used for treatment of BPD, but their use is challenging due to variability in treatment response.

Objectives/Goal: Previous pharmacometabolomics study has established patterns of metabolite levels with response to dexamethasone. We obtained additional patient samples for metabolomics analysis to find associations between the metabolome and dexamethasone response in a validation cohort.

Methods/Design: 14 infants provided 15 plasma and 12 urine samples. The measure of treatment response was the calculated change in respiratory severity score (deltaRSS) from pre-to-post treatment. Each metabolite was assessed …

Patient-Facing Antihemophilic Factor Clinical Decision Support Tool, Chandni Dargan

Research Days

Background: Hemophilia represents a medical condition suited to individualization. Adherence with prophylactic antihemophilic factor regimens ranges from 6%-167%. Clinical decision support tools (CDS) have been shown to improve guideline compliance and enhance patient adherence.

Objectives/Goal: The objective of this study is to evaluate the usability, usefulness, and satisfaction of a pharmacology-driven, patient-facing antihemophilic factor CDS.

Methods/Design: A patient-facing CDS was created to allow patients and families to explore factor levels at any time during their regimen and with the administration of different dosing regimens. Development followed a user-centered design process to ensure development of a product targeted to the needs …

Rates Of Physical Abuse Screening And Detection In Infants With Brief Resolved Unexplained Events (Brues), Angela Doswell

Research Days

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Background: “Apparent Life-Threatening Events” (ALTEs) have been associated with child physical abuse (CPA). In 2016, “Brief Resolved Unexplained Event” (BRUE) and development of its clinical guidelines and risk-stratification replaced ALTE. It is unknown if there is a similar association between BRUEs and CPA.

Objectives: To determine the rate of CPA in infants presenting with a BRUE, examine differences between infants with/without CPA, and examine rates of diagnostic testing used to detect CPA.

Methods/Design: This study was part of the BRUE Research and Quality Improvement Network, composed of 15 academic and community hospitals. Subjects were infants …