Medical Specialties Commons^™

Pharmacists’ Role In The Management Of Patients Receiving Dual Or Triple Antithrombotic Therapy, Laura Neubauer, Radhan Gopalani, Kristen De Almeida

All Publications

Purpose: Patients on dual and triple antithrombotic therapy present the therapeutic dilemma of mitigating bleed risk while sustaining antithrombotic efficacy. Lack of literature and variability in existing published guidance potentiates inconsistent management of these patients. Furthermore, suboptimal dosing of direct oral anticoagulants is relatively common. One study reported as high as 43% of patients receive higher and 13% receive lower than clinically indicated doses. These findings were associated with a significantly increased risk of major bleeding and incidence of stroke, thus highlighting the importance of selecting an ideal regimen. The purpose of this project is to highlight pharmacists’ role in …

Developing A 2-Week Surgery Bootcamp: A Needs Assessment Of Aspiring General Surgeons, Darci C. Foote, Victoria A. Roach

Conference Presentation Abstracts

No abstract provided.

Factors Associated With Reduced Infliximab Exposure In The Treatment Of Pediatric Autoimmune Disorders: A Cross-Sectional Prospective Convenience Sampling Study., Ryan S. Funk, Valentina Shakhnovich, Yu Kyoung Cho, Kishore Polireddy, Taina Hudson, Kyle Gress, Mara L. Becker

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Inadequate systemic exposure to infliximab (IFX) is associated with treatment failure. This work evaluated factors associated with reduced IFX exposure in children with autoimmune disorders requiring IFX therapy.

METHODS: In this single-center cross-sectional prospective study IFX trough concentrations and anti-drug antibodies (ADAs) were measured in serum from children diagnosed with inflammatory bowel disease (IBD) (n = 73), juvenile idiopathic arthritis (JIA) (n = 16), or uveitis (n = 8) receiving maintenance IFX infusions at an outpatient infusion clinic in a tertiary academic pediatric hospital. IFX concentrations in combination with population pharmacokinetic modeling were used to estimate IFX clearance. Patient …

Relationship Of Utilization Of Mental Health Care In Patients With Substance Use Disorders With And Without History Of Prior Incarceration, Linda Zhang, Harrison Ross Galicki, Gerald Demasters, William B. Dehart

Psychiatry

No abstract provided.

Short-Term Reoperation Risk After Surgical And Nonsurgical Management Of Isolated Greater Tuberosity Fractures, Akshar H. Patel, Olivia C. Lee, Michael J. O'Brien, Felix H. Savoie, William F. Sherman

School of Medicine Faculty Publications

Background: The outcomes and complication rates of patients with isolated greater tuberosity fractures are not well documented. The present study aimed to evaluate the reoperation rates, types of reoperations, and complications for patients undergoing open reduction internal fixation and those undergoing initial nonoperative treatment of isolated greater tuberosity fractures. Methods: An administrative claims database was queried from 2010 to 2018 for adult patients treated with open reduction internal fixation or initial nonoperative treatment within 6 weeks of sustaining a closed isolated greater tuberosity fracture. Reoperation rates, types of reoperations, local/surgical complications, and systemic complications for two cohorts were collected, and …

Temporary Intravascular Shunts After Civilian Arterial Injury: A Prospective Multicenter Eastern Association For The Surgery Of Trauma Study, Lily Tung, Jennifer Leonard, Ryan A. Lawless, Alexis Cralley, Richard Betzold, Jason D. Pasley, Kenji Inaba, Jennie S. Kim, Dennis Y. Kim, Kwang Kim, Bradley M. Dennis, Michael C. Smith, Margaret Moore, Christina Tran, Joshua P. Hazelton, Atlee Melillo, Tejal S. Brahmbhatt, Stephanie Talutis, Noelle N. Saillant, Jae Moo Lee, Mark J. Seamon

School of Medicine Faculty Publications

Introduction: We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia. Patients & methods: A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia). Results: The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP …

Treatment Of Erythrodermic Psoriasis With Apremilast, Olivia A. Gioe, Caroline Savoie, Elizabeth B. Grieshaber, Deborah C. Hilton

School of Medicine Faculty Publications

No abstract provided.

Pegloprastide-Based Ratiometric Fluorescence Imaging Detects Intraoperative Positive Margins In Real-Time, Sarah A. Mclaughlin, M Catherine Lee, Sheldon M. Feldman, Barry Rosen, Valerie P. Grignol, Anne M. Wallace, Nayana S. Dekhne

Conference Presentation Abstracts

Background/Objective: Positive margins detected after breast conservation surgery can result in the need for a re-excision or completion mastectomy. We hypothesized that pegloprastide combined with a ratiometric fluorescence imaging system would allow surgeons to detect positive margins in real time. Methods: Pegloprastide (AVB-620) was to be administered to patients 3-20 hours before the start of surgery. During the operation, initial primary tumor removal was performed unaided. Following primary resection, a fluorescence imaging system optimized for use with pegloprastide was used to assess the primary specimen and the cavity. Cavity shaves were taken when fluorescence above pre-specified thresholds were noted. Additional …

Chikungunya Outbreak In Karachi Pakistan 2016-2017: An Analysis Of Viral Isolates, Dhani Prakoso, Kelli Barr, Kehkashan Imtiaz, Joveria Farooqi, Erum Khan, Maureen Long

Department of Pathology and Laboratory Medicine

In December 2016 physicians in Karachi, Pakistan,witnessed an increase in patients presenting with febrile illness and severe polyarthralgia. Subsequently, chikungunya virus (CHIKV)) was isolated from three patients. This virus was sequenced and compared with other isolates of CHIKV obtained in India and Pakistan during recent outbreaks. Phylogenetic analysis indicated that the Karachi isolates were most similar to the East Central South African CHIKV lineage and showed sequence homology to isolates obtained in other parts of Pakistan and India. More importantly, two of the CHIKV isolates had a nucleotide substitution in the E1 gene corresponding to an amino acid change at …

Bmi And Associated Variables In A Pediatric Gender Clinic Sample, Mirae J. Fornander, Christine Moser, Anna Egan, Timothy A. Roberts

Presentations

Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight control behavior.

Objective: Describe BMI and the association of medication use, well-being, and recreational activities in treatment-naïve pediatric TGD patients.

Design/Methods: Chart review of 302 patients (age 3-19, 73.5% sex assigned at birth (SAB) female; 85.8% white) from 2017-2020. BMI was calculated by age and SAB using CDC growth charts. Parents reported medication use; parent and self-reported Pediatric Quality of Life (PEDS-QL) Well-Being and activities were surveyed electronically.

Results: By BMI category, 3.3% were underweight (BMI<5%); 49.4% were >85% and 29.5% fell >95%. Overweight …

Utility Of Diagnostic Testing In Patients Who Present With Brief Resolved Unexplained Event, Allayne Stephans, Kathryn Westphal, Erin Sullivan, Matt Hall, Risa Bochner, Adam Cohen, Jennifer Y. Colgan, Atima C. Delaney, Amy Delaroche, Thomas Graf, Beth Harper, Ron L. Kaplan, Hannah C. Neubauer, Mark I. Neuman, Nirav Shastri, Victoria Wilkins, Joel S. Tieder, Manoj Mittal

Presentations

Background: Well appearing infants commonly present with a history of a brief event characterized by changes in color, breathing, muscle tone, or level of alertness. In 1986 the National Institutes of Health coined the term ALTE (Apparent Life-Threatening Event) to describe these events. In 2016 the American Academcy of Pediatrics (AAP) published a guideline that updated the term ALTE to BRUE (Brief Resolved Unexplained Event). This guideline includes a more precise definition and limited recommendations for the evaluation of patients who are designated as lower risk for serious underlying diagnoses. A few small studies have examined the diagnostic yield of …

Use Of Clinical Criteria For Prediction Of Invasive Bacterial Infection In Febrile Infants: Evaluation Of The Pros Criteria, Lyubina Yankova, Mark Neuman, Marie Wang, Adrienne G. Deporre, Sanyukta Desai, Laura Sartori, Richard Marble, Lise Nigrovic, Rianna Leazer, Christopher Pruitt, Christopher Woll, Sahar Rooholamini, Frances Balamuth, Paul Aronson

Presentations

Background: In a 2004 study, the American Academy of Pediatrics Pediatric Research in Office Settings (PROS) network developed clinical criteria that had a sensitivity of 93.6% for identification of febrile infants at low-risk for invasive bacterial infection (IBI). Although application of the PROS criteria would reduce routine testing and emergency department (ED) evaluation for febrile infants in outpatient settings without readily available access to laboratory testing, these criteria have not been externally validated in a contemporary cohort.

Objective: To evaluate the sensitivity of the PROS criteria for IBI in febrile infants ≤60 days old.

Design/Methods: We performed a secondary analysis …

Obesity Does Not Increase Risk For Kidney Replacement Therapy (Krt), But Weight Reduction Improves Kidney Function In Children With Chronic Kidney Disease (Ckd), Amy Kogon, J Roem, Mark Mitsnefes, Babette Zeme, Bradley A. Warady, Susan Furth, Nancy Rodig

Presentations

Background: Obesity is prevalent in pediatric CKD, but its impact on CKD progression is unclear.

Objective: To determine the relationship between obesity/weight changes with CKD progression among children and adolescents enrolled in the Chronic Kidney Disease in Children (CKiD) study.

Design/Methods: Participants were categorized based on body mass index (BMI) as normal, overweight (OW) or obese and those who were underweight were excluded. Kaplan-Meier survival curves and parametric failure time models determined the association of baseline BMI category on time to KRT stratified by non-glomerular (NG) and glomerular (G) etiology of CKD. The distribution of changes in BMI categories within …

Impact Of Covid-19 On Inpatient Utilization And Outcomes For Children With Medical Complexity, Jessica L. Markham, Troy Richardson, Adrienne G. Deporre, Ronald Teufel, Adam Hersh, Eric Feegler, Ryan Antiel, Adam Goldin, Arda Hotz, Jayme Wilder, Samir Shah

Presentations

Background: Children with medical complexity (CMC) are a growing subpopulation of children who require intense engagement with the healthcare system including the involvement of multiple subspecialists and ancillary services. CMC often receive definitive care within children’s hospitals where subspecialty services are concentrated. While studies have reported reductions in emergency department visits and hospitalizations for generally healthy children during the COVID-19 pandemic, the overall impact of the pandemic on CMC has not been well described.

Objective: The objective of this study was to describe the impact of the early COVID-19 pandemic on inpatient utilization for CMC presenting to US children's hospitals. …

Contraception Counseling Of Adolescents Seeking Care In Pediatric Emergency Departments, Cynthia Mollen, Romina Barral, Tara Ketterer, Jungwon Min, Laurel Gabler, Lauren Poole, Amber Adams, Elizabeth Miller, Aletha Akers, Melissa K. Miller

Presentations

Background: Efforts to increase contraceptive use among adolescents are urgently needed. One approach is to use clinical settings that do not routinely provide contraception services, such as the emergency department (ED). Though many are amenable to ED-based contraceptive care, best practices for providing this care are largely unexplored.

Objective: To assess intention to initiate contraception among adolescent females immediately after receiving ED-based contraceptive counseling, and to assess counseling feasibility, contraception initiation and completion of a follow-up visit for contraceptive care.

Design/Methods: Prospective cohort study in two urban pediatric EDs. Using webinar modules and in-person sessions, advanced practice providers (APPs) were …

Lessons From The Pandemic: How A Children’S Hospital Responded To The Challenges Of Covid-19, John Lantos, Paul Kempinski, Laurie Ellison, Jennifer Watts, Angela Myers

Presentations

The COVID-19 pandemic challenged doctors and hospital administrators as did no other event in our lifetimes. Leaders needed to develop a pandemic command structure with the agility to respond to rapidly evolving situations. They had to deal with drastic financial implications, develop new methods of delivering health care, and collaborate regionally. They learned the importance of communication with staff, policy makers, the local medical community, and the public. They had to allocate of scarce resources internally and externally, and balancing rational policy making against irrational fears. For children’s hospitals, some specific challenges included determining our role in a pandemic that …

The Effect Of Covid-19 On The Detection And Prevalence Of Suicidality In Adolescents, John Lantos, Hung-Wen Yeh, Fajar Raza, Mark Connelly, Shayla Sullivant

Presentations

Background: The COVID-19 pandemic saw changes to the delivery of health services and concerns about psychological morbidity not directly related to COVID infection. We analyzed the effects of the pandemic on our hospital’s program to screen adolescents for suicidality.

Objective: To determine the effect of the COVID-19 pandemic on 1) a hospital-wide screening program for suicidality in teens; and 2) the prevalence of positive screens for suicidality.

Design/Methods: Our study population was all patients > 12yo seen as inpatients or in the ED or clinics at a children’s hospital in Apr-June in 2019 (T1) and 2020 (T2). Eligible pts were screened …

Using Standardized Scripting To Improve Antibiotic Stewardship In A National Pediatric Urgent Care Collaborative, Amanda Nedved, Melody Fung, Cindy Liu, Rana Hamdy, Amanda Montalbano

Posters

Background: A study using administrative data reported urgent care providers as having the highest rates of inappropriate antibiotic use for upper respiratory illnesses. In a national survey, pediatric urgent care providers reported family expectations as a primary driver for prescribing inappropriate antibiotics. Standardized scripting has been effective at reducing unnecessary antibiotics while increasing family satisfaction.


Objective: To reduce inappropriate prescribing for upper respiratory infections (acute otitis media (AOM), otitis media with effusion (OME), and pharyngitis) in pediatric urgent cares by 20% by December 1, 2020 through use of standardized scripting in Year 2 of a national pediatric urgent care quality …

Pediatric Resident Reflections From A Non-Medical Home Visit Of A Child With Medical Complexity, Emily J. Goodwin, Sheryl Chadwick, Deejo Miller, Kathryn Taff, Amanda Montalbano

Posters

Background: Pediatric residents typically only interact with patients and families in healthcare settings which limits the opportunity to fully understand the patient and family experience. Encounters with children with medical complexity (CMC) that only relate to illness or health monitoring can anchor residents to false preconceptions and limit their ability to practice patient- and family-centered care (PFCC). The core principles of PFCC include acknowledging patient and family expertise and strengths, encouraging their input, and appreciating the value of their observations and perceptions.


Objective: To explore how a home visit program with patients and families serving as faculty could instill the …

Household Income, Psychosocial Stressors, And Risk Factors For Sleep-Related Infant Deaths, Jeffrey D. Colvin, Isabella Zaniletti, Carolyn Ahlers-Schmidt, Vicki Collie-Akers, Christy Schunn, Rosemary Nabaweesi, Debbie Cheney, Rachel Y. Moon

Posters

Background: Sleep-related infant deaths (e.g., SIDS, accidental suffocation, undetermined) are the leading cause of postneonatal mortality. Infants from low income families have higher rates of sleep-related deaths. Other risk factors for sleep-related death include nonsupine sleep position, bedsharing, maternal smoking, sleeping in separate room, soft bedding, and breastfeeding <8 weeks. Little is known about how these risk factors vary by income or if psychosocial stressors, social services, and education of parents from healthcare providers about risk factors influence these risks among low income families.


Objective: Aim 1: Describe differences in risk factors for sleep-related infant death by family income. Aim 2: Among low income families, describe differences in risk factors by psychosocial stressors, services, and risk-factor education.


Design/Methods: We analyzed 2016-2017 CDC Pregnancy Risk Assessment Monitoring Study (PRAMS) data in 47 states. PRAMS questions mothers of …

Simulation Based Clinical Systems Testing In The Pediatric Emergency Department To Prepare For Covid-19 Pandemic, Christopher S. Kennedy, Marc Sycip, Lisa Ell, Shautonja Woods

Posters

Background: The COVID-19 prompted pediatric emergency departments (PED) to prepare for a surge in patients. In response, guidelines developed represent “work as imagined” and may not reflect work as done. In situ simulations could identify gaps and help to mitigate errors. Simulation-based clinical systems tests (SbCSTs) can detect latent safety threats (LSTs) in systems design.


Objective: Our aim was to use SbCSTs combined with rapid cycle training to test hospital system modifications for ED preparation. This method represenst a new application of SbCSTs. The research questions were in 2 frames: 1. Can rapidly deployed SbCSTs identify LSTs and recommendations for …

A Smarter Way To Round, Charles Maloy, Adrienne G. Deporre, Erica Adams, Jessica Olson, Amber Hunley, Darcy K. Weidemann

Posters

Background: Communication is a key driver of health care outcomes. Poor communication practices contribute to sentinel safety events, poor family/patient experiences, and delays in care. Use of checklists in the healthcare setting is important to the development of high reliability and is increasingly common, however, the development and implementation of medical checklists for the standard patient floor are inadequately described.


Objective: To develop a sustainable rounding checklist for multidisciplinary discussion of patient safety measures and clinical plans.


Design/Methods: Key stakeholders in the rounding process (subspecialty and general pediatrics physicians, resident physician, bedside nurses, and nursing leadership) created a rounding checklist …

A Deleterious Ephb4 Mutation Suppresses Prox1 Expression And Disrupts Lymphatic Development In Neonatal Non-Immune Hydrops, Gangaram Akangire, Heather Menden, Sheng Xia, Atif Ahmed, Venkatesh Sampath

Posters

Background: Non-immune hydrops fetalis is often a fatal condition and in 20% of cases related to lymphatic anomalies. Maldevelopment of lymphatic valves, atretic or absence of central lymphatic vessels has been described in hydrops fetalis, but the genetic basis of these anomalies remains undefined. Recent reports suggest that Ephrin type B receptor 4 (EPHB4) gene has a significant role in embryonic development of lymphatic system. To test the hypothesis that EPHB4 mutations can cause hydrops fetalis, we combined whole exome sequencing (WES) with functional and pathological analysis of an infant who succumbed to neonatal hydrops.


Objective: To discover the possible …

A Novel Way To Describe Variation In Antibiotic Use, Adrienne G. Deporre, Troy Richardson, Jason Newland, Mark Neuman

Posters

Background: A broader understanding of antibiotic variation can inform stewardship efforts. Diversity indices are frequently calculated in ecologic studies to measure the variety of species in a given habitat, however they have not yet been used to study variation in antibiotic use in the healthcare setting.


Objective: To develop a novel assessment of antibiotic variation, based on the breadth of an antibiotic’s associated conditions as well as its use, measured by days of therapy (DOT).


Design/Methods: We assessed antibiotic use in children aged 60 days-18 years hospitalized at a US Children’s hospital included in the Pediatric Health Information System (PHIS) …

Parental Health Literacy And Acute Care Utilization In Children With Medical Complexity, Emily J. Goodwin, Joy L. Solano, Jessica L. Bettenhausen, Ryan Coller, Adrienne G. Deporre, Rupal Gupta, Kayla R. Heller, Lauren Jones, Leah Jones, Kathyrn Kyler, Ingrid Larson, Laura Plencner, Margaret Queen, Timothy Ryan Smith, Tyler Smith, Jacqueline M. Walker, Margaret Wright, Isabella Zaniletti, Jeffrey D. Colvin

Posters

Background: Inadequate health literacy, defined as inadequate ability to find, understand and use health information is associated with poor health outcomes and high health care costs. Children with medical complexity (CMC) have high rates of acute care utilization. Understanding parental health literacy in CMC and its relationship to acute care utilization may inform interventions designed to lower utilization.


Objective: To examine parental health literacy for CMC and determine its association with acute care utilization.


Design/Methods: In this single-site cross-sectional study, 250 parents of CMC completed a self-administered survey (response rate of 66.1%). CMC were included if they had a complex …

Medical Neglect: Trends In Reporting Practices And Patient Characteristics, Danielle Horton, Emily Killough, Mary Moffatt

Posters

Background: Medical neglect has significant consequences on child health and well-being. Improved processes for defining, recognizing, and reporting medical neglect are needed, however there is limited published data on the subject. Insight into patient characteristics and current reporting practices will help identify areas for intervention to improve outcomes for children at risk for medical neglect.


Objective: To describe characteristics of children identified for concern of medical neglect and trends in reporting of cases to child protective services (CPS).


Design/Methods: We performed a 1-year retrospective descriptive study of subjects < 18 years of age at a single, tertiary-care, academic pediatric institution for whom a Patient at Risk (PAR) assessment was completed exclusively for the concern of medical neglect. The PAR is a unique institutional process by which health professionals and social workers document concerns for child maltreatment. Medical records were reviewed for data regarding demographics, medical history, health care utilization and psychosocial risk factors. The role of the initiating provider and healthcare setting in which the PAR was recorded were also obtained.


Results: Of 270 children with a PAR completed for medical neglect concerns, …