Department of Pediatrics Research Retreat
Vanderbilt University Medical Center
More info: https://pediatrics.vumc.org/research-retreat
Filter displayed posters (167 keywords)
High-Efficiency Neutrophil Isolation Protocol and 3D Neutrophils function Testing
Castillo-Galvan, Ricardo MD MPH; Bennett, Monique PhD; Soper, Nicole MLI; Thomsen Isaac MD MSCI
Harnessing cell-penetrating peptides for non-viral gene editing
I.C. Vallecillo-Viejo 1,2, R.B. Fletcher 2, and C.L. Duvall 2
Characterization of LPS Induced Leukocyte Distribution at the Early Blastocyst Implantation Site of Mice
Sourav Panja and Bibhash C. Paria
Transpulmonary Estrogen Gradient and Estrogen Receptor Density in Pulmonary Arterial Hypertension
Kelsey W. Malloy, MD, Stephanie Hart, MS, Evan L. Brittain, MD MSCI, Anna R. Hemnes, MD MSCI, Eric D. Austin, MD MSCI
A Single Cell Atlas of Late Lung Development Identifies Unexpected AT1 Expression Patterns and Mesenchymal Wnt Patterning
Nicholas M. Negretti, Erin J. Plosa, John T. Benjamin, Bryce A. Schuler, A. Christian Habermann, Christopher Jetter, Susan H. Guttentag, Timothy S. Blackwell, Nicholas E. Banovich, Jonathan A. Kropski, Jennifer M. S. Sucre
a3b1 Integrin Regulates AEC Survival and Differentiation During Lung Development
Kimberly Ferguson, Pete Gulleman, Chris Jetter, Jen Sucre, Erin Plosa
Apelinergic Signaling: A New Target for Pulmonary Hypertension Associated with Bronchopulmonary Dysplasia
Alice Hackett, Nick Negretti, Erin Plosa, John Benjamin, Christopher Jetter, Jonathan Kropski, Jennifer Sucre
STUDY DESIGN To characterize expression of apelin and its receptor in lung development, we performed single cell RNA sequencing (scRNAseq) across 7 time points from embryonic day (E) 15 to postnatal (P) day 14. To study apelin expression during lung injury, we have developed a murine model combining hyperoxia (70% oxygen from postnatal day (P) 1-5) and inflammation with intratracheal administration of lipopolysaccharide on PN3 and 4. For validation, we examined human lung tissue from preterm infants with and without lung injury. Apelin and apelin receptor expression were localized in lung tissue using RNA in situ hybridization (ISH), with quantification using Halo software. To further characterize our lung injury model phenotype, we performed echocardiography on mice at 8 weeks of life both in control and hyperoxia groups.
RESULTS By scRNAseq, apelin and its receptor are expressed by distinct subpopulations of endothelial cells in the lung, with apelin expression in a specialized population of alveolar endothelial cells. In normal development, Apelin expression increases before birth at embryonic day (E) 18 and is relatively constant across the lifespan. In acute lung injury, we found decreased expression of apelin by RNA ISH in endothelial cells when compared with normoxia-exposed controls at P5 (p<0.001). This decrease in apelin expression persisted during recovery at P14 (p<0.01) and P28 (p<0.01). There were no significant changes in apelin receptor expression with injury. Examination of human infant lungs in the saccular stage showed decreased apelin expression after 4 days of mechanical ventilation when compared with infants who were never mechanically ventilated (p<0.001). Preliminary results of echocardiography in injured mice aged to 2 months demonstrates a significant decrease in right ventricular stroke volume and increase in right ventricular wall thickness in injured mice relative to controls.
CONCLUSION Apelinergic signaling is a conserved pathway that emerges in the saccular stage of lung development. During acute neonatal injury and recovery, there is a significant decrease in apelin expression. We have also preliminarily characterized the echocardiographic phenotype of our hyperoxia model. Future work to target the apelin pathway may identify novel therapies in infants with BPD and PH.
Age-determined expression of priming protease TMPRSS2 and localization of SARS-CoV-2 in lung epithelium
Bryce A. Schuler, A. Christian Habermann, Erin J. Plosa, Chase J. Taylor, Christopher Jetter, Nicholas M. Negretti, Meghan E. Kapp, John T. Benjamin, Peter Gulleman, David S. Nichols, Lior Z. Braunstein, Alice Hackett, Michael Koval, Susan H. Guttentag, Timothy S. Blackwell, Steven A. Webber, Nicholas E. Banovich, Vanderbilt COVID-19 Consortium Cohort, Human Cell Atlas Biological Network, Jonathan A. Kropski, and Jennifer M.S. Sucre
Study Design: We interrogated expression profiles of genes linked to SARS-CoV-2 infectivity by analyzing a single-cell RNA sequencing (scRNA-seq) dataset of mouse lung across five time points from embryonic day 18 (E18) to postnatal day 64 (P64). To spatially and temporally localize expression of candidate genes, we performed RNA in situ hybridization (RNA-ISH) (with automated quantification) and protein immunofluorescence. Developmental gene expression patterns in mice were compared to those at both the RNA and protein level in human lung samples in infants (0-2 years, n=7), children (3-17 years, n = 9), and adults (54–69 years, never smokers, n = 4). Lung autopsy specimens from patients who died of COVID-19 complications were analyzed for co-localization of SARS-CoV-2 viral particles and candidate genes.
Results: Expression of the cellular receptor for SARS-CoV-2, ACE2, did not significantly change over development whereas TMPRSS2, the canonical protease that mediates cellular entry for coronaviruses, showed increased expression with aging in mice and humans. Expression of TMPRSS2 was highest in ciliated cells and type I alveolar epithelial cells (AT1). Analysis of autopsy tissue from fatal COVID-19 cases detected SARS-CoV-2 RNA most frequently in ciliated and secretory cells in airway epithelium and AT1 cells in peripheral lung. SARS-CoV-2 RNA was highly colocalized with TMPRSS2.
Conclusions: Together, these data demonstrate the cellular spectrum infected by SARS-CoV-2 in lung epithelium and suggest that developmental regulation of TMPRSS2 may underlie the relative protection of infants and children from severe respiratory illness.
Funding: Supported by NIH grants R38-HL143619, K08HL143051 (to JMS), K08HL130595 (to JAK), R01HL145372 (to JAK/NEB), P01HL092470 (to TSB), K08HL127102 (to EJP), K08HL133484 (to JTB), R01AI077505 (to DWH), P30AI110527 (to SAM), R01AI142095 (to SAK/SAM), and TR002243.
Mentors: Dr. Jennifer Sucre; Jennifer.firstname.lastname@example.org
The Novel Role of Extracellular Superoxide Dismutase in the Function of TNFα and Integrin Signaling in Pulmonary Endothelium
Michael R Miller MD, PhD, Hyehun Choi PhD, Steven Koch PhD, Ryan Stark MD, Fred Lamb, MD, PhD
Anti-CD45RB Prolongs Survival in a Stringent Acute GVHD Model
Aryaz Sheybani, Chris Wilson, Emilee Hoopes, Daniel Moore
BVES AND RSK1 IN THE INTESTINAL EPITHELIUM
Conrad B. Cox, Yash A Choksi, Christopher S Williams
Objective: The aim of this project was to determine whether BVES’s role in intestinal epithelial barrier homeostasis is RSK1 dependent.
Methods and Results: After yeast two-hybrid screening, we confirmed an interaction of BVES with RSK1 through co-immunoprecipitation. We then demonstrated an inverse relationship in BVES/RSK1 protein expression in tissue culture where increases in BVES expression correlated with decreased total expression and phosphorylation of RSK1. We also demonstrated this inverse relationship using immunohistochemistry to examine RSK1 cellular localization within the colon crypt of wild type (WT) and Bves-/- mice. WT colon crypts revealed RSK1 near the cell membrane and almost exclusively in terminally differentiated cells on the apical side of the colon, while Bves-/- crypts showed RSK1 in the cytoplasm throughout the entirety of the crypt including the crypt base. Next, in order to determine whether this inverse relationship existed in patients with Crohn’s disease, we utilized RNA-scope to measure BVES transcript in samples from patients with UC. We found that BVES was increased in human colitis as compared with adjacent normal colon epithelium. We them demonstrated this finding in a separate RNA-seq data set from patients with pediatric UC. There was a similar inverse relationship between BVES and RSK1 transcripts, and both were affected by the degree of colitis. In order to demonstrate this functional effect of this inverse relationship we disrupted RSK1 activity in BVES knockdown cell lines using an ATP-competitive N-terminal kinase domain inhibitor, BI-D1870, and are currently investigating the effect this has on various surrogate markers of epithelial barrier function.6
Conclusion: BVES and RSK1 interact at the protein level and have an inverse relationship as demonstrated in Bves-/- mice and patients with IBD. Ongoing studies are needed to determine its biological significance
The Impact of Social Distancing on Children with Down Syndrome
Jenesis Yanez MD, Krissy Kalemaris DPT, Mattie Goosetree BA, Angela Maxwell-Horn MD
Objective In early 2020 COVID-19 began to sweep across the United States. People were urged to “social distance”1. This entailed staying at least 6 feet apart from other people to help stop transmission of COVID-19. People with Down syndrome are generally considered to be very social. Their social skills are generally a strength of their cognitive profile2. This study sought to understand how social distancing affects the lives of children with Down syndrome.
Study Design This survey-based study was approved by the Vanderbilt University Medical Center (VUMC) Institutional Review Board, with data collected between April and June of 2020. All data were collected via Research Electronic Data Capture (REDCap). The survey consisted of 13 questions asked to the caregivers of children with Down syndrome. The questions inquired about eating and sleeping habits, mood, and activities during the period of social distancing due to the COVID-19 pandemic. Survey data was collected from the family members of people who had attended the Down Syndrome Clinic at VUMC between March 2019 and March 2020. One hundred thirty-one families answered the survey about their child with Down syndrome.
Results In response to the question, “Did your child socially distance themselves during the pandemic?” n=124 (94.7%) responded yes and n=7 (5.3%) responded no. Children with Down syndrome had been restricted from most of their routine activities during the pandemic, traditional school (n=122/93.1%), religious activities (n=63/48.1%), therapies (n=100/76.3%), playdates and social gatherings (n=89/67.9%), community outings (n=97/74.0%), team sports (n=20/15.3%) and other (n=7/5.3%)(Table 3). In response to the question, “In general, what is your child’s overall mood at baseline (before social distancing or the pandemic)?,” most families reported that their children were generally happy n=88 (67.2%). Most parents reported that their children were eating as they normally did at baseline (n=95/72.5%); n=36 (27.5%) reported that their child did have a change in their eating habits. Parents reported that their children had been engaged in a variety of activities since most routine group activities were cancelled.
Conclusions Most families of children with Down syndrome where following the recommended guidelines and having their children stay socially distant during the COVID-19 pandemic. All the children who had previously attended school outside of the home had stopped going due to school closure. Most children (55.7%) did not have changes in their mood. Of those that did experience changes, 61.2% of them were reported to be more irritable/anxious. As noted earlier, children with Down syndrome are often noted for their happy and amiable dispositions2. Their social relatedness to others is often a strength. It can thus be postulated that the pandemic related social distancing has interfered with the social relationships and interactions that provided a source of happiness and fulfillment to children with Down syndrome. This combined with the disruption in normal routine has likely led to a more irritable and anxious mood in children with Down syndrome.
Nebulized Albuterol Delivery is Associated with Decreased Skeletal Muscle Strength in Comparison with Metered-Dose Inhaler Delivery Among Children with Acute Asthma Exacerbations
Catherine Burger, MD; Danica F. Vendiola; Donald H. Arnold, MD, MPH
Study Design: We recruited children aged 5-17 years who presented to the ED with acute asthma exacerbation and received MDI (Ventolin®, 90 mcg/puff) or continuous nebulized (10 mg/hr) albuterol. Participants performed 3 strength measurements with a digital hand-dynamometer (Lafayette 5030D1) before and 1-hour after initiation of albuterol treatment. Asthma characteristics, Acute Asthma Severity Research Score (AAIRS), total dose and delivery method were recorded. We used the Wilcoxon rank sum method and multivariable linear regression to examine associations of delivery method with skeletal muscle strength change.
Results: A total of 50 participants received albuterol by MDI (n=40) or nebulizer (n=10) during the first hour of treatment, with median [IQR] MDI albuterol dose 8 [4, 8] puffs (720 mcg median total dose) and nebulized dose of 10 mg. In univariate analyses, change of skeletal muscle strength was 2.4 [-5, 13] % after MDI and -7.8 [-23.3, 5.1; range] % after nebulized albuterol (p = 0.036, Wilcoxon rank sum, Figure 1). In the multivariable linear regression model, nebulized albuterol was associated with a -12.9 [95% CI -27.6, -0.2, p= 0.014] % change of skeletal muscle strength in comparison with MDI albuterol, after adjusting for age and pre-treatment AAIRS severity.
Conclusions: Nebulized albuterol is associated with decreased skeletal muscle strength during asthma exacerbations, whereas albuterol administration via MDI is not. Additionally, there was notable variability of skeletal muscle strength change after nebulization (IQR -23.3, 5.1]. In children with greater decreases this may be clinically meaningful and treatment with MDI over nebulization may be beneficial when either route is deemed clinically appropriate.
Parental Primary Language, Access to Care, And Developmental Delays in Neonates
Lindsay Sternad, MD, Melissa McPheeters, PhD MPH, Elizabeth McNeer, MS, Theresa Scott, MS, Carolyn Heinrich, PhD, Gilbert Gonzales, PHD MHA, Stephen W. Patrick, MD MPH
Study Design: In this retrospective cross-sectional study we used data from the 2016-2018 National Survey of Children’s Health (NSCH). Our outcomes were (1) caregiver report of access to care, including a comprehensive medical home and developmental therapies, and (2) caregiver reported prevalence of combined developmental delay, defined as: difficulty using hands or with coordination (if child < 5 years), difficulty walking/climbing stairs or dressing (6-17 years), speech delay, and/or general developmental delay. We also examined descriptive differences in infant characteristics (e.g., birth weight, sex), social determinates of health (e.g., maternal education, marital status, insurance status) and timing of parental immigration to the US. All analyses used survey weights to provide nationally representative estimates.
Results: Our weighted sample represented a total of 68.2 million children, 7.9 million of which were born preterm (prior to 37 weeks gestation). Children born to Spanish speakers were more likely to be uninsured (p<0.001), more likely to have public health insurance (p<0.001), and less likely to be born in the US (p<0.001). Spanish primary language caregivers were less likely to have a high school education (p<0.001) than English speaking caregivers, and were more likely to be born outside the US (p<0.001). Children born to Spanish speakers were less likely to have a comprehensive medical home compared to English speakers (29.2% vs. 49.4%, p<0.001; see Table 1). Spanish speaking families were also less likely to report that their child received developmental therapies (p=0.007) or had a special education plan (p<0.001). Spanish speakers were more likely than English speaking caregivers to report their child having difficulty with coordination (29.6% vs 12.6%, p=0.04) and difficulty using hands (28.4% vs 10.5%, p=0.02). There were no statistically significant differences between Spanish speaking families and English speaking families in regards to speech delays or general developmental delays.
Conclusions: In a national sample, Spanish speaking families were more likely to report that their child had specific developmental delays, and that they faced greater barriers to accessing healthcare, including a comprehensive medical home and developmental therapies. Our results suggest that children in these families may be at higher risk of experiencing certain early developmental delays without appropriate care. Addressing language-based barriers may be important to establishing equitable outcomes for vulnerable children.
OUTCOMES ASSOCIATED WITH A PEDIATRIC ICU SEDATION WEANING PROTOCOL
Kimberley Harper MD, Jessica Anderson PharmD, Julie S. Pingel PharmD, Katharine Boyle MD, Li Wang MS, Christopher J. Lindsell PhD, Ann Sweeney MD, Kristina A. Betters MD, FAAP
Study Design: This observational cohort study compares outcomes pre and post-implementation of a risk stratified sedation weaning protocol in a medical/surgical PICU. The protocol provides weaning guidance based on duration and dosage of sedation infusions and was implemented in September 2019. Patients requiring opioid, benzodiazepine and/or dexmedetomidine infusions were weaned per protocol, except patients receiving chronic sedation medications or end of life patients. Total duration of sedation wean, ICU length of stay, and withdrawal assessment tool (WAT) scores, were collected by chart review for a 12 month period pre and post-protocol. In an interrupted time series analysis, we fit linear models for each outcome to evaluate the effect of the sedation weaning protocol. Both the main effect and interaction with time were evaluated.
Results: There were 49 patients pre and 47 patients post-protocol implementation. Mean opioid wean duration pre-protocol was 16.9 days (SD 20.9) and 12.1 days (SD 10.5) post-protocol (p= 0.17), with a change in slope (interaction with time) of -0.01 days per day. This slope value correlates to an average reduction of opioid wean duration by 0.01 days for each day during the protocol period. The pre-protocol mean benzodiazepine wean duration was 14.1 days (SD 14.5) vs. 11.0 days (SD 13.5) post-protocol (p=0.42), with a slope of -0.05 days per day. For dexmedetomidine/clonidine, pre-protocol mean wean duration was 15.9 days (SD 20.7) vs. 8.1 days (SD 9.2) post-protocol (p=0.04), with a slope of -0.03 days per day. Average WAT score was 2.1 (SD 0.95) pre vs. 1.8 (SD 0.95) post, with a slope of 0.003 points per day. ICU length of stay mean was 23.9 days (SD 21.8) pre vs. 25.6 days (SD 24.4) post, with a slope of -0.006 days per day.
Conclusion: Implementation of a risk stratified sedation weaning protocol in the PICU resulted in a decrease in average total duration of sedation wean for opioids, benzodiazepines and dexmedetomidine/clonidine. The association of protocol implementation with WAT scores and ICU length of stay requires further exploration.
The association of duration of breastfeeding and childhood asthma outcomes
Keadrea Wilson, Tebeb Gebretsadik, Margaret A. Adgent, Christine Loftus, Catherine Karr, Paul E. Moore, Sheela Sathyanarayana, Nora Byington, Emily Barrett, Nicole Bush, Ruby Nguyen, Terry Hartmann, Kaja LeWinn, Alexis Calvert, Frances A. Tylavsky, Kecia N. Carroll
SAFETY AND EFFICACY OF FECAL MICROBIOTA TRANSPLANTATION FOR RECURRENT CLOSTRIDIOIDES DIFFICILE INFECTION IN IMMUNOCOMPROMISED PEDIATRIC PATIENTS
Katie R. Conover, MD, Imad Absah, MD, Sonia Ballal, MD, David Brumbaugh, MD, Stanley Cho, MD, Maria Cardenas Fernandez, MD, Elizabeth Doby Knackstedt, MD, Alka Goyal, MD, M. Kyle Jensen, MD, Jess L. Kaplan, MD, Richard Kellermayer, MD, Larry K. Kociolek, MD, Sonia Michail, MD, Maria Oliva-Hemker, MD, Anna Reed, MD, Madison Weatherly, Stacy A. Kahn, MD, Maribeth R. Nicholson, MD
Study Design We identified IC patients in our national pediatric FMT registry, who were treated with FMT for rCDI with minimum 12-week follow-up. We collected data using a 76-item survey that was completed for 72 patients at 9 centers, of which 42 subjects met inclusion criteria. We report FMT efficacy and adverse events.
Results Our 42 subjects ranged from 18 months to 18 years old. Etiologies for IC included: solid organ transplantation (18), malignancy (12), primary immunodeficiency (10), or other chronic conditions (2). Success rate was 79% after first FMT and 86% after second FMT. Five post-FMT hospitalizations were likely FMT related. There were no deaths or infectious complications related to FMT.
Conclusions The success rate of FMT for rCDI in this pediatric IC cohort aligned with adult literature. Absence of death or infection from FMT provides reassurance, although severe complications, including aspiration pneumonitis and intestinal perforation, highlight the need for heightened vigilance. We recommend a careful assessment of risk versus benefit prior to considering FMT in pediatric IC patients.
Cardiac biomarkers in a select cohort of pediatric heart disease: Galectin-3, hsCRP and NT-proBNP.
Benedicto A. Fernandes MD, Muhammad Ghani, Wu Gong PhD, Christopher Lindell PhD ,David Bichell MD, Mark A. Clay MD
VARIABLE COURSE OF RECOVERY AND ASSOCIATED GUT MICROBIAL CHANGES FOLLOWING FECAL MICROBIOTA TRANSPLANTATION FOR D-LACTIC ACIDOSIS IN CHILDREN
Busing, Jordan, MD; Bulik-Sullivan, Emily; Fouladi, Farnaz; Carroll, Ian; Thomsen, Kelly F; Fodor, Anthony; Gulati, Ajay S; Nicholson, Maribeth
Population Pharmacokinetics/Pharmacodynamics of Beta-Lactam Antibiotics in Critically Ill Patients Receiving ECMO or CRRT
Stephanie L. Rolsma, MD, PhD, Ahmad Dbouk, MD, Brian C. Bridges, MD, William H. Fissell, IV, MD, Matthew S. Shotwell, PhD, C. Buddy Creech, MD, MPH
Study Design: We will enroll approximately 100 patients in VUMC intensive care units receiving ECMO or CRRT who are also receiving cefepime, piperacillin-tazobactam or meropenem. We anticipate that patients will contribute an average of 5-10 plasma samples during the 14-day study period. Though the intent of the study is to use random sampling, there are specific high-priority timepoints that provide high value information about PK parameters for each drug. We will measure drug concentrations of cefepime, meropenem, and piperacillin-tazobactam in plasma samples using C18 HPLC with UV and fluorescence detection. After enrollment, patient information will be extracted from the EMR and recorded in a REDCap database. This will include demographic data (e.g., age, sex, race, and ethnicity, anthropomorphic measurements), relevant comorbidities (e.g., sepsis, acute kidney injury, hepatic dysfunction), and recent laboratory data. PK models for the pooled concentration data will be explored by non-linear mixed effects modeling. Covariate analysis will examine the potential correlation between model parameters and demographic/clinical factors.
Preliminary Results: We have enrolled and collected samples from 28 patients to date. This includes six pediatric patients on CRRT, one pediatric patient on ECMO, and 21 adult patients on ECMO. Most pediatric patients on CRRT received cefepime (4/6, with one each receiving meropenem or piperacillin-tazobactam). For adult patients, eight patients received cefepime, eight received meropenem, and five received piperacillin-tazobactam. A mean of three samples were collected per participant [range 3-9]. Infectious etiologies in participants were highly variable. Fifteen adult patients were diagnosed with SARS-CoV-2 during admission. Three pediatric CRRT patients were diagnosed with fungal infections within seven days of enrollment in the study. Five adult patients had positive blood and/or urine cultures within seven days of sample collection: two patients with Staphylococcus epidermidis (blood), one with Candida guilliermondii (blood), and three with Candida species (urine). Six adult patients also had positive cultures from endotracheal tube specimens, including three with MRSA, two with Pseudomonas aeruginosa, and one with Escherichia coli.
Conclusions: Our study will be among the first to derive popPK models of cefepime, meropenem and piperacillin-tazobactam exposure in children receiving ECMO or CRRT and adults receiving ECMO. Results from this study will lay the foundation for personalized TDM for three commonly used antimicrobial agents in these populations.
Propafenone Adverse Events in the Pediatric and Young Adult Population
Sudeep Sunthankar, Prince Kannankeril, Frank Fish, Andrew Radbill, and Sara Van Driest
Shunting Away from Unnecessary Radiation: Predicting Neurosurgical Shunt Failure & Emergency Evaluations
S. Barron Frazier, MD; Claci Walls, MD; E. Haley Vance, DNP, CPNP-AC; Christopher Bonfield, MD; Holly R. Hanson, MD, MS
Study Design: Retrospective cohort study was performed from 01/2018-01/2020 for all encounters with neurosurgical shunt evaluation in the PED. Demographics, presenting symptoms, initial vital signs, exam findings, and outcomes were collected to determine predictors for shunt malfunction or infection. Risk factors for repeat evaluation include age, primary language, missed neurosurgical appointment in the last 3 months, and distance from the hospital. Pearson’s chi-squared test and Wilcoxon’s test were used for statistical analysis.
Results: 249 patients underwent 463 shunt evaluations during the study period. Headaches and nausea and/or vomiting were found to be predictors for shunt malfunction/infection (p<0.001) whereas shunt malfunction/infection were statistically less likely in patients with seizures and fever (p=0.01). Vital signs were not found to be predictive of shunt malfunction or infection. Exam findings found exposed tube shunting or overlying shunt rash as reliable predictors for shunt infection (p<0.001, <0.01). Risk factors for repeat evaluation were non-English primary language (p=0.007) and closer proximity to the hospital (P<0.001).
Conclusions: Predicting neurosurgical shunt evaluations can be difficult given vague symptom presentation. Headache and vomiting is concerning for shunt malfunction. Shunt infection was rare, and fever or seizure alone, especially with history of seizure disorder, should not always lead to neurosurgical evaluation. Further investigation on recurrent visits is needed and whether primary language neurosurgical education or increased case management or outpatient visits reduce PED evaluations.
Utilization of Echocardiography Following Repair of Congenital Heart Disease in the Current Era
Adam Skaff, Nishma Valikodath, Justin Godown, David Parra
Study Design: All patients <18y undergoing surgical repair of congenital heart disease were identified from the Pediatric Health Information System (PHIS) using ICD-9 and ICD-10 procedure codes from 2010-2019. Surgical repairs included atrial septal defect, ventricular septal defect, tetralogy of Fallot, superior cavopulmonary anastomosis, total cavopulmonary anastomosis, coarctation, atrioventricular septal defect, transposition of the great arteries, total anomalous pulmonary venous return, truncus arteriosus, truncus arteriosus with interrupted aortic arch, and Norwood. Detailed billing data were used to assess the frequency of post-operative echocardiograms and phase of hospital care. All surgeries were grouped by their Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) scores. The mean and median number of post-operative echocardiograms performed for each RACHS-1 score and the lengths of stay were calculated. Data across all the PHIS hospitals were graphically compared using box plots with interquartile ranges for each RACHS-1 score.
Results: A total of 37,238 patients were identified for inclusion across 48 centers. The number of postoperative echocardiograms and length of stay increased with increasing RACHS-1 score (Table). When corrected for hospital length of stay, patients undergoing congenital heart disease repairs with higher RACHS-1 scores had lower echocardiogram utilization per day compared to patients with lower RACHS-1 scores (Figure 1). Within each RACHS-1 score there was significant variability in echocardiogram utilization across centers (Figure 2).
Conclusion: There has been little reported regarding the utilization of echocardiography following surgical repair for congenital heart defects. Our study found a positive correlation between the number of echocardiograms performed and post-operative length of stay with increasing surgical complexity as defined by the RACHS-1 scoring system. However, utilization of echocardiogram when adjusting for length of stay is lower in lesions with a higher RACHS-1 score. There is significant variation in the use of echocardiography across congenital heart surgery centers.
Echocardiographic findings in adolescents presenting for sports clearance following COVID-19 infection
William A. McEachern, MD, MPH, Gary Coburn, RCCS, RDCS (AE), RCS, CCT, David A. Parra, MD
Methods: We reviewed outpatient transthoracic echocardiograms obtained between 11/01/2020 and 12/31/2020 for clearance for return to activity/sports of patients aged 12-18 with a history of mild or moderate COVID infection. Patients had at least one of the following: chest pain, shortness of breath, palpitations, syncope, or abnormal electrocardiogram. Two groups with similar complaints but without a known history of COVID referred during 1.) the same timeframe and 2.) the pre-COVID era were reviewed for comparison. Univariable analysis was performed using Spearman’s rho and Wilcoxon rank-sum test. Multivariable analysis utilized linear and logistic regression following multiple imputation of minimal missing data.
Results: Our study groups are detailed in Table 1. In the prior COVID group, in addition to 1 patient with depressed left ventricular ejection fraction (LV EF), 6 others had abnormal LV global longitudinal strain (GLS) despite normal LV EF. In an intragroup analysis of the COVID cohort, controlling for age and gender, the presence of chest pain correlated with a decrease in global circumferential strain rate (GCSR) and trended in that direction for global circumferential strain (GCS). An abnormal electrocardiogram correlated with decreased right ventricular GLS and free wall strain. In intergroup univariable analysis, prior COVID was associated with lower LV GCS and GCSR and right ventricular GLS and free wall strain. The association for LV GCS and GCSR was also observed when controlling for age, gender, and LV EF but disappeared upon adding presence of any symptoms and of an abnormal electrocardiogram as independent variables. No association between prior COVID and right ventricular strain metrics was seen in multivariable analysis.
Conclusions: In adolescents with prior mild or moderate COVID illness, ventricular function by conventional metrics is not categorically different from those without a COVID history. The presence of symptoms or an abnormal electrocardiogram may contribute to prediction of decreased myocardial strain; the clinical significance of abnormal strain with preserved EF is unclear. Future studies may further elucidate whether myocardial strain indices augment conventional metrics in evaluating cardiac risk in this cohort.
PEDIATRIC CYSTIC FIBROSIS AND THE RELATIONSHIP BETWEEN GASTROINTESTINAL MUCINS, THE MICROBOME, AND INFLAMMATION
Rachel Bernard, DO MS, Andrew Monteith PhD, Eric Skaar PhD MD, Kathryn M. Edwards MD, Jennifer Spinler PhD, Melinda Engevik PhD, Maribeth R. Nicholson MD, MPH
DEVELOPMENT, VALIDATION, AND RANDOMIZED TRIAL OF A REAL-TIME RISK PREDICTION MODEL FOR PEDIATRIC VENOUS THROMBOEMBOLIC EVENTS
Shannon C. Walker MD, Henry J. Domenico MS, Benjamin French PhD, Ryan P. Moore MS, C. Buddy Creech MD, MPH, Daniel W. Byrne MS, and Allison P. Wheeler MD, MSCI
Prediction of Infection Risk Following Pediatric Cardiac Surgery
Kaitlin Williamson, MD; Ritu Banerjee, MD, PhD; Daniel Fabbri, PhD
Evaluation of Point-of-Care Glucose Analysis in Ill Neonates
David Brooks, MD, James H. Nichols, PhD, Justin Gregory, MD, MSCI
DESIGN We will simultaneously collect blood samples from the capillary circulation via heel puncture and from the arterial circulation by intravascular catheter. Using the arterial sample, we will quantify the difference in glucose concentrations measured by the ACCU-CHEK® Inform II versus the lab-based YSI glucose analyzer. We will then determine the difference between capillary glucose (measured by the ACCU-CHEK® Inform II) and arterial plasma glucose (measured by the YSI analyzer). Using the YSI analyzer, we will measure plasma lactate as a surrogate for tissue perfusion. We will also quantify plasma triglyceride, albumin, and immunoglobulin G levels, as these large molecules have the potential to confound POC glucose results.
RESULTS We are planning a study with 60 participants. Prior neonatal data indicate that the variance in the difference in glucose concentrations obtained from capillary blood using the ACCU-CHEK® Inform II versus from whole blood obtained using laboratory analysis is normally distributed with standard deviation of 4.7 mg/dL. We will be able to detect a true mean difference between POC and reference glucose measurements of 2.0 mg/dL with probability (power) of 0.9. To assess the agreement between the ACCU-CHEK® Inform II and YSI Analyzer, statistical analysis will be performed using Bland-Altman analysis. We will also perform a series of multivariable linear regression analyses with mean bias as the dependent variable. A sample size of 60 patients allows for as many as 6 covariates to be studied in our multilinear regression model.
CONCLUSION This study will provide valuable insight on the reliability of the ACCU-CHEK® Inform II glucose meter in preterm and ill neonates and potentially will impact how clinicians in the NICU use this device for glycemic monitoring.
A PROSPECTIVE ANALYSIS OF COVID-19 VERSUS INFLUENZA SEVERITY IN TYPE 1 AND TYPE 2 DIABETES
Justin Gregory MD; Elizabeth Keiner MD; Allison McCoy PhD
The Use of Anti-Factor Xa Assays in a Comprehensive Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol is Associated with Increased Survival and Significant Cost Savings
Shawn B. Sood MD, MBA, Louisa Anne Walker, Rangaraj Ramanujam Ph.D., Daphne Hardison RN, BSN, Jennifer Andrews MD, Andrew H. Smith, MD, MSCI, MMHC, Brian C. Bridges MD
CARDIOPULMONARY ALTERATIONS IN FORMER PRETERM INFANTS
Meredith S. Campbell, MD1, Jonathan H. Soslow, MD, MSCI2, Evan L. Brittain, MD, MSCI3, Jennifer M. S. Sucre, MD1, Thomas G. Stewart, PhD4, Eric D. Austin, MD, MSCI5
Study Design: In a cohort study of former ELGANs using cardiac magnetic resonance imaging (CMR), we are testing the hypothesis that presumably healthy former ELGANs have detectable cardiopulmonary abnormalities in mid-childhood. Cases are defined as ELGANs between the ages of 9 and 17 years; controls are healthy subjects born at term in the same age range. Subjects are examined in the pediatric clinical research center, provide a urine sample, and undergo CMR. The primary endpoint is the ratio of right to left ventricular end diastolic volume (RVEDV:LVEDV), which is a surrogate marker for pulmonary vascular resistance by CMR. Secondary endpoints include 6-minute walk test, quality of life including the Peds QL Cardiac Questionnaire, markers of oxidant stress (urinary isoprostanes and isofuranes), and clinical metrics including height, weight, resting heart rate, and blood pressure.
Results: Since February 2020, 34 subjects have completed the study (12 cases and 22 controls). Of the remaining 26 study subjects needed for completion, 19 (11 cases and 8 controls) are scheduled for an upcoming study visit, leaving 7 additional subjects needed. CMR data analysis and investigator unblinding will be performed upon completion of study enrollment. In addition, urine samples will be sent for isoprostane and isofuran levels to VUMC Eicosanoid Core Laboratory.
Conclusion: Growing data in young adults born premature with no history of adult cardiopulmonary disease suggest a high prevalence of occult pulmonary vascular disease characterized by elevated pulmonary vascular pressure, stiffness, and RV dysfunction. Yet, key opportunities remain which this study will address, including: (a) identify the timing of these changes relevant to the pediatric life course; and (b) identify specific, potentially modifiable targets for therapeutic interventions in mid-childhood or even younger (e.g., infancy) to prevent or treat morphologic and functional cardiopulmonary impairments before adulthood.
Cumulative Incidence of Autism Spectrum Disorder in Tennessee
Katelyn Rossow, Alison Vehorn, Zachary Warren
Study Design: Our data source was Vanderbilt’s Research Derivative clinical informatic platform which contains the electronic health record (EHR) data for all patients seen at VUMC including ICD codes used at each visit. Children were included as an ASD case if they were born between the years of 1997-2018; had at least one ICD code of ASD; last address in the EHR was listed in TN; and were not listed as deceased in the EHR. Incidence curves were calculated per birth cohort year dividing the number of cases of ASD per year by the total number of same aged-children living in Tennessee in the year of interest.
Results: A model for cumulative incidence curves for children living in Tennessee during birth cohort years 1997-2018 was successfully created using EHR data as shown in the figure. Final incidence estimates for ASD varied by birth cohorts with the lowest incidence of 0.42% in 18 year olds born in 1997/1998 with the highest of 1.01% in 3 and 4 year olds born in 2013/2014. Our methods yielded lower estimates than current CDC estimates. This figure shows an increase in autism incidence over time and across birth cohort years that has not yet flattened. Importantly, data for this study were extracted from the EHR over a 6 week period. Quantifying and creating the cumulative incidence curves took less than two weeks.
Conclusion: Utilizing EHR based ASD identification might provide an efficient way to rapidly model ASD incidence. Future directions include linking these methods to statewide educational data and Medicaid data. This strategy could potentially provide a new method to model ASD incidence in real time in a cost effective manner.
Spirometry and functional muscle assessments in patients with Duchenne Muscular Dystrophy
Jacob A. Kaslow, Andrew G. Sokolow, William B. Burnette, Thomas Donnelly, Jonathan H. Soslow
Study Design Forty-nine patients with DMD were enrolled and underwent accelerometry and QMT at baseline, 1-year and 2-year clinic visits. Past medical history, current and previous medications, and ambulatory status were collected at each visit. Patients wore an Actigraph GT3X accelerometer on their dominant wrist and ankle for 7 days and 24 hours per day. The QMT assessment performed at each visit utilized a handheld myometer with arm, leg and total QMT scores being recorded and indexed to age. Temporally associated pulmonary function testing was obtained from the electronic medical record. Spearman correlation coefficient was used to assess the relationship between spirometry and functional muscle testing.
Results At the initial clinic visit, forced vital capacity percent predicted (FVC%p) showed strong correlation with aspects of both ankle and wrist accelerometry. Awake ankle VM had the highest relationship with FVC%p (rho=0.8091, p = 0.0026), although all recordings showed either strong or moderate correlation. While FEV1%p showed a similar pattern to FVC%p, the overall strength of the relationship between accelerometry and spirometry was not as strong with all ankle and wrist recordings demonstrating a moderate correlation with FEV1%p. Maximal inspiratory pressure showed strong correlation with both wrist VM/min (rho=0.7697, p=0.009) and ankle VM/min (rho=0.7818, p=0.0075). There was variable correlation with MEP and accelerometry measures over the course of the study with no consistent findings. Arm and leg QMT exhibited moderate to strong correlation with all spirometry measurements. Total QMT count had strong correlation with both FVC%p (rho=0.7735, p=0.0001) and FEV1%p (rho=0.7006, p=0.0008). Despite lower number of patients performing MIP and MEP, both had a strong relationship with total arm QMT counts (rho=0.7792, p =0.0079 and rho=0.8160, p=0.004, respectively). Longitudinal monitoring demonstrated a steady decline in accelerometry VM counts and QMT measurements.
Conclusions Lung function, specifically FVC%p and FEV1%p, has strong correlation with both upper and lower extremity skeletal muscle functional testing. This relationship was not affected by steroid use or ambulatory status. These data provide insight into the pathogenesis of pulmonary function decline and highlight the need for further exploration of the connection between skeletal muscle and respiratory disease progression.
A Pragmatic Low Carbohydrate Diet Intervention Changes Neither Carbohydrate Consumption nor Glycemia Appreciably in Adolescents and Young Adults with Type 1 Diabetes
Sara H Duffus, MD; Katie Coate, PhD; Sarah Jaser, PhD; Kevin D Niswender, MD, PhD; Justin M Gregory, MD
Materials and Methods: We randomized 29 patients with T1DM aged 13-21 years who were using both an insulin pump and continuous glucose monitor (CGM) to 1 of 3 interventions: an LCD (25-35% of daily caloric intake from carbohydrates, n=11), an equicaloric SCD (45-65% carbohydrate, n=9), or a general diabetes education program with no specific dietary recommendations (control, n=9). The 12-week intervention included 3 telephone sessions to reiterate the nutrition or general diabetes education and reinforcing text messages 2-4 times weekly. Glycemic outcomes included change in HbA1c and CGM parameters.
Results: Carbohydrate consumption was similar at baseline between LCD and SCD groups, then decreased by a median of 69 grams/day in the LCD group and increased by 3 grams/day in the SCD group over 12 weeks (Δ = 72 grams/day, 95% CI ≅ -38 to 125 grams/day, figure 1A). Carbohydrate consumption decreased by 11 grams/day in the control group. Adherence to diet varied widely, and there was no statistical difference in the change in carbohydrate consumption between groups (p=0.27, figure 1B). There was no clinically or statistically significant difference between groups for change in HbA1c (p=0.46), CGM average blood glucose (p=0.59), CGM time in range (p = 0.41), CGM coefficient of variation (p=0.36), or total daily dose of insulin (p=0.82), figure 1C-F.
Conclusions: Although participants received significant nutritional instruction and ongoing education, possibly reflected in a trend towards decreased carbohydrate consumption in the LCD group, adherence to the prescribed diet varied so widely that carbohydrate consumption was not appreciably different between groups, and all glycemic measures remained unchanged. These findings suggest that nutrition education alone is insufficient to mitigate dysglycemia in adolescent patients with T1DM. While small, uncontrolled studies have promoted LCDs as a means to improve glycemia, it is possible that these highly motivated participants not only consistently restricted carbohydrate consumption but also excelled in all aspects of diabetes self-care. This pragmatic study suggests that clinic-based LCD interventions are unlikely to improve glycemia in the general adolescent T1DM population.
EFFECT OF TIME ON QUALITY OF PARENT-CHILD COMMUNICATION IN PEDIATRIC CANCER
Brittany A. Cowfer, MD, Mary S. Dietrich, MS, PhD, Terrah Foster Akard, PhD, RN, CPNP, FAAN
Study Design: This secondary analysis utilized T1 data from a larger randomized controlled trial. Participants included children (7 to 17 years) with relapsed or refractory cancer and their parents, who spoke English, were not cognitively impaired, and had internet access. Children and parents completed the Parent-Adolescent Communication Scale (PACS), a 20-item measure of communication quality, with openness and problem subscales. Spearman’s Rho coefficients assessed correlations between PACS scores and time since diagnosis/relapse.
Results: There was a statistically significant negative correlation between parent PACS scores and time since child’s initial cancer diagnosis (Spearman’s Rho = - .21, p = .02), indicating a tendency for overall worsening communication as time since diagnosis increased. There was a positive correlation between parent PACS problem scores and time since diagnosis (Spearman’s Rho = + .22, p = .01), indicating more problematic communication as time since diagnosis increased. Correlations of time since relapse and PACS scores were small and not statistically significant.
Conclusions: Parent-child communication may worsen over time following a child’s initial cancer diagnosis. Families may benefit from continued involvement of interdisciplinary teams, including psychologists, social workers, child life specialists, and palliative care providers, to support parent-child communication beyond the new-diagnosis period as the family encounters additional challenges of advanced childhood cancer.
Risk factors for post-operative nausea and vomiting after tonsillectomy and ondansetron administration are older age, female sex, and less time under anesthesia.
Katherine Black, B. Randall Brenn, Dan Roden, Sara Van Driest
Objectives: Our primary objective is to evaluate clinical risk factors for PONV after receiving ondansetron and undergoing tonsillectomy in the pediatric population. Our secondary objective is to look at risk factors for worse outcomes after tonsillectomy as measured by increased emergency department visits and time spent in the post-anesthesia care unit (PACU).
Study Design: We performed a retrospective cohort study using BioVU, the VUMC DNA biorepository linked to de-identified electronic medical records. Individuals in BioVU who were less than 18 years old at the time of tonsillectomy and received ondansetron on the day of surgery were included. Exclusion criteria were a diagnosis of cyclical vomiting syndrome, or prior surgical procedures such as gastrectomy, gastrostomy, fundoplication, esophageal surgery, or bronchoscopy. Peri-operative data were used to determine the primary outcome of PONV defined as needing a dose of an anti-emetic or anti-nausea medication while in the PACU. Time spent in the PACU, emergency department (ED) visits within 7 days of surgery, and continued nausea and vomiting on follow-up phone calls after 24 hours were also recorded using a secure REDCap study database.
Results: 733 individuals were included in our study. PONV was seen in 126 (17.2%). The median age was significantly higher in those children that experienced PONV than those without at 7.6 years [interquartile range (IQR 4.0-9.6)] vs 6.3 years (IQR 5.5-11.2), respectively (p = 0.005). Females were more likely to experience PONV, (58.0% vs 45.1%; p=0.009). There were no differences in race or ethnicity between the two groups. The American Society of Anesthesiology (ASA) score, an objective way to evaluate pre-operative co-morbidities, did not differ between groups. The time spent under anesthesia was significantly shorter in subjects with PONV compared to subjects without PONV [45 (IQR 37-57) vs 55 min (IQR 41-64), p<0.001]. Those with PONV spent significantly less time in PACU phase 1 but longer in phase 2, where patients must tolerate oral intake prior to discharge. Total time spent in the PACU was longer in those with PONV compared to without PONV at 175 min vs 140 min (p=0.003). There were no differences in immediate PONV and ED visits within a week or continued nausea or vomiting on follow-up phone call between groups.
Conclusion: Increased age and female sex were associated with increased risk of PONV. Those with PONV spent less time under anesthesia and spent a longer time recovering in the PACU. Since ondansetron is metabolized by the polymorphic CYP2D6 enzyme, our next analyses will include CYP2D6 activity scores to determine the impact of genetic variation on ondansetron response.
Pediatric firearm-related hospital encounters increase during Covid-19 pandemic
Kelsey A.B. Gastineau, MD, Derek J. Williams, MD, MPH, Matt Hall, PhD, Monika K. Goyal, MD, MSCE, Jordee Wells, MD, MPH, Katherine L. Freundlich, MD, Alison R. Carroll, MD, Whitney L. Browning, MD, Kathleen Doherty, MD, Cristin Q. Fritz, MD, MPH, Patricia A. Frost, MD, Heather Kreth, PsyD, Carlos Plancarte, MD, MSC, Shari Barkin, MD, MSHS
Differences in Body Surface Area Assessment of Burns Between Emergency Medical Services and Burn Physicians
Duy P Tran, DO; Donald H Arnold, MD, MPH; Callie M Thompson, MD; Neal J Richmond, MD; Stephen Gondek, MD, MPH; Rebecca S Kidd, MD
EPIDEMIOLOGY OF PEDIATRIC FOREIGN BODY INGESTIONS AMIDST THE CORONAVIRUS DISEASE 2019 PANDEMIC AT A TERTIARY CARE CHILDREN’S HOSPITAL
Lauren J. Klein, MD, Katherine Black, MD, Michael Dole, MD, Danielle K. Orsagh-Yentis, MD
The Physical Abilities and Mobility Scale as a New Measurement of Functional Progress in the PICU
Allison Weatherly, MD; Li Wang, BS; Christopher Lindsell, PhD; Katherine Hedden, PT, DPT, PCS; Camille Marsden, MOT/OTR-L; Jennifer Pearson, MS/OTR-L; Kristina Betters, MD, FAAP
Study Design: Single center, retrospective chart review of patients ≥ 2 years of age admitted to the PICU or pediatric cardiac ICU at an academic tertiary care pediatric hospital from July 1, 2018-March 30, 2019. Patients who were not on the EM protocol (i.e. patients with ICU length of stay (LOS) <72 hours or patients who met EM exclusion criteria) and those who had <2 PAMS scores were excluded from analysis. Spearman’s correlation coefficients were used to assess the association between the FSS and PAMS. Comparisons of scores in relation to disposition used a Mann-Whitney U-test.
Results: 130 patients met inclusion criteria. Median age 9.4 years, median ICU LOS 9 days, and median hospital LOS 16 days. Primary diagnoses included respiratory failure or insufficiency (20%), cardiac disease (15%), and status post elective surgery (15%). Patients had a median of 7 physical and/or occupational therapy visits while in the ICU. The association between the PAMS and FSS was strong (rho = -0.85), but non-linear. As the FSS ranged from 26 to 13, the PAMS ranged from 20 to 40. However, for an FSS between 7 and 13, the PAMS ranged between 40 and 95, suggesting much greater sensitivity to small changes in function. In comparing patients discharged to an inpatient rehabilitation facility (n=17) to those discharged home (n=105), the median FSS score at discharge was 9 vs 13, while the median PAMS at discharge was 66 vs 40. The difference in magnitude of the differences (4 vs 26) further suggests PAMS exhibits greater sensitivity to small changes in functional status.
Conclusions: The PAMS is a useful tool to assess and track functional progress in critically ill children and may be helpful in prognosticating final disposition needs. Next steps include investigating its use in quantifying patient progression during hospitalization and for informing disposition decisions.
INCIDENCE OF SUICIDAL BEHAVIORS AND ASSOCIATIONS OF PATIENT CHARACTERISTICS IN CHILDREN BEFORE AND DURING THE SARS COV-2 PANDEMIC
Hannah Smith, MD; James Gay, MD; Donald H. Arnold, MD, MPH; Emily Kleiman, MD; Amelia Wong, MD; S. Barron Frazier, MD; Elizabeth Keiner, MD; Amelia Wong, MD; Marla C. Levine, MD
Study Design: We screened and recorded relevant variables from the electronic medical records of patients requiring psychiatric consultation in the PED between March 2018 and March 2021. Patients were included for analyses if they had documented concern for SI or SA. Patient characteristics including age, gender, race, zip code, insurance, mode of arrival, results of Columbia-Suicide Severity Rating Scale, ED arrival date and time, ED length of stay, and disposition were collected from patient’s electronic medical record. For patients admitted to the hospital, additional information was obtained including hospital length of stay, status of medical clearance on admission, avoidable hospital days and barriers to discharge. Descriptive statistics will be reported as means (SD), median [IQR], and proportions as appropriate. Multivariable logistic models will be used to examine associations between explanatory variables and outcomes of interest (SI, SA), with reduction of model covariates as needed to avoid overfitting. This study was approved by the Vanderbilt IRB (protocol # 161952).
Results: A total of 6,594 charts were reviewed and 2,757 had a presenting chief complaint of SI and SA and were included for analyses. An additional 3,837 charts were reviewed for SI or SA. Of these charts, 1,385 revealed suicidality on secondary review. Characteristics of patient population pending.
Applying a Risk Prediction Model for Non-neutropenic Fever in a Cohort of Pediatric Stem Cell Transplant Patients
Kasey Jackson, MD1*, Victoria Trebochi, MD2*, Zhiguo Zhao, MS3, Carrie Kitko, MD1, Jim Connelly, MD1, Rich Ho, MD1, Ritu Banerjee, MD4, PhD, Daniel Dulek, MD4, Debra Friedman, MD, MS1, Adam Esbenshade, MD, MSCI1
The Impact of Digoxin Use on Interstage Mortality in the Current Era
Rachel Klausner, David Parra, Karen Kohl, Tyler Brown, Garick Hill, LuAnn Minich, Justin Godown
Study Design: This study was a secondary analysis of the NPC-QIC database and included all patients who survived to hospital discharge following S1P. Patient demographics and digoxin use at S1P discharge were compared between eras (1: 2009–2014 vs. 2: 2015–2019). Patients with a NEONATE score (excluding digoxin) >8 were considered high-risk. A Cox proportional hazard model assessed the impact of digoxin on ISM and freedom from readmission in era 2 after adjusting for known risk factors.
Results: Era 1 had 1400 (46.8%) patients and era 2 had 1589 (53.2%). Digoxin use increased across eras (22.4% vs. 61.7%, p<0.001). The proportion of high-risk patients was greater in era 2 vs. era 1 (20.3% vs. 9.1%, p<0.001), but there was no difference in risk between those who did vs. did not receive digoxin in era 2 (p=0.82). In era 2, Digoxin use was independently associated with reduced ISM (AHR 0.59, 95% CI 0.35-0.97, p=0.038, Fig. 1A) and greater freedom from readmission (AHR 0.41 95%CI 0.32 – 0.54, p<0.001, Fig. 1B).
Conclusions: Digoxin was independently associated with improved outcomes including a reduction in ISM and greater freedom from readmission in the current era. The lack of improvement in ISM in the current era may be secondary to an increase in the acceptance of high-risk patients.
Developing and Testing of Clinical Decision Support for Neonatal Ventilator Management
Lindsey A. Knake MD, Mhd Wael Alrifai MD, MS, Christoph U. Lehmann MD, L. Dupree Hatch MD, MPH
A Multimodal Black History Tour: Increasing Physician Confidence with Critical Race Theory and Trauma-Informed Care
Natalia Sidhu, MD; Rosemary Hunter, MD
We aimed to produce a multimodal Black history tour of North Nashville via exploration of pre-selected historically significant locations in North Nashville coupled with more in-depth investigation via selected readings, podcasts and documentaries to ultimately increase physician comfort in the critical race theory impacting patients from the area.
Study Design & Results Although still in progress, we aim to perform a targeted cohort educational intervention with survey. Pediatrics residents will take a baseline knowledge test regarding concepts related to historical themes in North Nashville. Confidence scores via Likert scale will also be collected regarding critical race theory and provision of trauma-informed care. Following the multi-modal tour, the same knowledge assessment will be administered as well as a post-survey measuring self-reported confidence.
Statistical analysis of pre- and post-knowledge scores as well as confidence scores will be undertaken, and we anticipate preliminary results will be available for future presentation.
Conclusion Prior to this intervention, no such medical education curriculum exists. We aim to decrease knowledge and confidence gaps to provide a meaningful way for learners to understand the interplay between historical trauma and systemic racism to thus feel more empowered to address health disparities among our black patients and their families and to provide them with tailored community resources.
Improving Education in Pediatric Airway Management for Pediatric Resident
Claci Walls, Roselyn Appenteng, Rebecca Kidd, Swathi Eyyunni
Methods: A pediatric airway toolkit curriculum was developed that highlighted airway management and procedural skills. Curriculum was taught to pediatric residents during their emergency medicine rotation. Participants completed a pre and post survey which detailed the frequency and comfort level on a 5 point likert scale of performing the following procedures: Bag Valve Mask (BVM), Laryngeal Mask Placement (LMA), Oropharyngeal Airway Placement (OP), Nasopharyngeal Airway Placement (NP), Endotracheal Intubation (ETT), and overall comfort level with respiratory distress. Curriculum was taught in-person from November 2019 to March 2020 with simulation. Due to the COVID-19 pandemic, the curriculum was transitioned virtually from May 2020-present. In July of 2020 pre/post quizzes to assess knowledge were added. Data was collected via Redcap and statistical analysis was performed.
Results: There were 69 total pre survey responses and 46 post survey responses. As of July 2020, with the addition of a pre/post quiz, there are 32 pre survey responses and 21 post survey responses.
The data from Nov 2019 to June 2020 demonstrated that the mean frequency of all 5 procedures prior to the curriculum which ranged from 1.125 (SD= 0.49, OP) to 2.125(SD=0.91, BVM) was similar to the frequency after the curriculum 1.08(SD=0.28,OP) to 2.12 (SD=0.97, ETT). Overall resident comfort level averaged 2.6875 (SD=0.90) and 3.24(SD=0.78) before and after the curriculum respectively. A Wilcoxon rank sum test demonstrated that resident comfort with BVM placement was statistically significantly higher after the curriculum (p=0.02) and comfort level with the overall management of respiratory distress also increased (p=0.01).
From July 2020 to January 2021, 14 participants completed both the pre/post survey. Statistical analysis via paired t-Test was performed. There was a statistically significant increase in the means for comfort level for NP placement (p=0.02), LMA placement (p=0.03), OP placement (p=0.04), ETT placement (p=0.04), and overall comfort level (p=0.03). The pretest mean was 60.2% and posttest mean was 67.3%, there was not a statistically significant difference between the pre/post test (p=0.15) or the frequency of procedures between the two groups.
Conclusions: The curriculum increased the overall pediatric resident comfort level with management of respiratory distress and different airway adjuncts. However, sample size was insufficient to demonstrate a difference in pre/post test scores. The frequency of resident participation in the management of airway procedures remained relatively similar before and after the intervention. However, opportunities for participation were impacted by COVID-19 safety protocols. This data further highlights the need for creative opportunities for pediatric resident education on airway management.
Virtual and Asynchronous Teaching of Computer-Assisted Diagnosis of Genetic Diseases Seen in Clinics
Mary Grace Hash, Philip D Walker, Heather E Laferriere, Leeanna Melton, Lauren S Heller, & John A Phillips III
Study Design: On 7 November 2020, a cohort of 32 MCP were invited to participate in our IRB exempt quality improvement study. Our cohort included Clinicians (Clinical Geneticists, Neonatologists, Neurologists, Obstetricians, and Pediatric Surgeons) (40%), Molecular Geneticists/Cytogeneticists (16%), Nurse Practitioners (13%), and Genetic Counselors (31%). Three surveys were distributed to assess: 1) expectations about using the DDSS before instruction (Baseline Survey), 2) satisfaction of instruction on using the DDSS to solve case problems (Training Survey), and 3) the clinical impact of using the DDSS (After >1 Month Use Survey). Surveys were built in REDCap and placed on the Vanderbilt/Meharry ROCKET platform to maximize convenience for participant access. ROCKET also hosted links to teaching videos (total 15 minutes) and practice case problems (vignettes: 5 clinical, 2 with CV results from NGS, and 2 optional with microarray results with ROH).
Results: Thirty-one participants have completed the Baseline Survey. Most (68-84%) participants strongly agreed/agreed that the DDSS would likely be easy to use; be useful to their work and for clinical decision support, and would help them in making a differential diagnosis and/or prioritize CVs. Of the participants, 15/31 (48%) have completed their Training Survey and all 15 achieved passing scores on the 7 required case problems (mean= 95, range= 80-100, with scores of 10, 9, 8 if they ranked the correct diagnosis as 1, 2, 3, etc. in order), 8/15 also successfully completed the optional cases with ROH (mean= 89, range= 70-100), and 0/13 requested additional training. Of these 15 participants, 75% reported that the DDSS was very easy/easy to use and 69% and 56% were completely satisfied with the video training non-video learning resources, respectively. Twelve participants also completed their After >1 Month Use Survey. Of these 12, 75% and 92% strongly agreed/agreed that the DDSS was useful to their clinical work and for clinical decision support, respectively.
Conclusions: Our early results show that a variety of MCP could successfully use the DDSS following asynchronous, virtual teaching to 1) generate computer-assisted, ranked DDx of rare genetic disorders using DDSS to analyze phenotypic features that they extracted from case vignettes which required only 10-19 minutes/case and 2) produce formatted outputs of phenotypic features and DDx following loading of an annotated NGS variant table. This approach could facilitate iterative and synergistic interactions between clinicians and lab specialists in making such diagnoses and in prioritizing CVs.
Creating and Implementing a Subspecialty Nighttime Curriculum
Jennifer Laws, MD; Whitney Browning, MD
Application of Kern's 6-Step Approach to the Pediatric Critical Care Resident Rotation
Jonathan Boyd, MD; Jennifer King, MD, PharmD
Study Design Curriculum assessment was through pre and post rotation Redcap surveys and board style questions in a prospective cohort.2,3
Methods Literature review revealed no comprehensive pediatric critical care curricula. Rotation feedback from the prior 3 years was reviewed and demonstrated opportunities for improvement in the didactic curriculum, especially regarding lack of time and frequent interruptions. Faculty and residents were surveyed to identify which objectives required revision, barriers to education, and comfort with commonly encountered diagnoses; this data were used as a targeted needs assessment to update learning objectives in conjunction with ABP content specifications.
Resident orientation was also modified to include basics of mechanical ventilation. Other formal teaching opportunities during the rotation included 12 formal didactics and 4 high fidelity simulation scenarios. Residents completed pre and post rotation quizzes of board style questions.
Results Seventy-five percent of eligible participants completed the surveys and rotation quizzes.
Pretest scores were equal before and after implementation (71%). Post test scores were 65% and 68%; this was not statistically different by t test. Residents scored as expected on PREP questions (74% expected, 70% by residents).
Residents reported improved comfort in PCCM topics post rotation. When comparing pre and post intervention groups, no difference was found in post rotation comfort attributable to the new curriculum. Residents cited frequent interruptions as a barrier to learning less often post intervention (from 81 to 67%).
Conclusions A PCCM curriculum was revised but did not statistically improve resident comfort or knowledge compared to the prior curriculum. Future directions include review of simulations to assess learner’s actions in clinical scenarios and implementation of case based didactics.
References 1. Kern DE, Thomas PA, Hughes MT. Curriculum Development for Medical Education: A Six-Step Approach. 2. PA Harris, R Taylor, R Thielke, et al, Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support, J Biomed Inform. 2009 Apr;42(2):377-81. 3. PA Harris, R Taylor, BL Minor, et al, REDCap Consortium, The REDCap consortium: Building an international community of software partners, J Biomed Inform. 2019 May 9 [doi: 10.1016/j.jbi.2019.103208]
Facts Behind the Fad: A Descriptive Survey of a Curriculum to Promote E-Cigarette Education in High School Students
Lauren S. Starnes, MD, MEd; Samuel Lazaroff, MD; Marni Krehnbrink, MD; Jacob Kaslow, MD; McKenzie Vater, MD
Study Design: Pediatric residents created a PowerPoint that they presented via Zoom to students at a local high school. Google form surveys were administered via QR code prior to the presentation (“pre-survey”) and at the conclusion (“post-survey”). The pre-survey contained true/false questions to gauge baseline knowledge. The post-survey consisted of five-point Likert scale questions assessing whether participants would decrease their use of vape products or encourage their peers to do so. This scale ranged from completely disagree (1) to completely agree (5). Understanding of the side effects of vaping was assessed on both surveys using a similar Likert scale. A total of 36 students were involved in the study. Students were informed that survey participation was optional, anonymous, and would not impact their class grade.
Results: The response rate was 83.3% (n = 30) for the pre-survey. Of respondents, seventeen students (56.7%) reported that they have never tried vaping, eight students (26.7%) have tried vaping but will never do it again, four students (13.3%) occasionally vape, and one student (3.3%) vapes multiple times per week. Twelve students (40.0%) thought vaping is safer than smoking cigarettes. Six students (20.0%) thought that vaping is not addictive. Following curriculum implementation, the post-survey response rate was 55.6% (n = 20). Students marked an average of 4.78 (SD = 0.55) in response to the statement, “Following this presentation, I will decrease my use of vaping.” Students marked an average of 4.11 (SD = 1.28) in response to the statement, “Following this presentation, I will discourage others to use vaping products.” Students were also asked to respond to the statement, “I understand the side effects of vaping,” on both surveys. A Wilcoxon rank sum test showed that the median for the pre-survey was 4.5 (IQR 4, 5), and the post group was 5 (IQR 5, 5) with p-value 0.0372.
Conclusions: Our pre-survey highlighted the need for adolescent education around the risks of vaping. Nearly half of the population surveyed have tried vaping or currently vape. Almost half believed vaping is safer than smoking cigarettes and many felt it has a low addiction risk. Post-survey responses demonstrated the program convinced students to decrease their use of vaping. Students reported on average that they would discourage others from the use of e-cigarettes. However, the standard deviation was wide, and several students disagreed with this. Future steps involve including information in the curriculum on the importance of discouraging their peers from vaping and advice on to have these conversations. Finally, comparisons of the pre- and post-surveys showed that the curriculum improved students’ understanding of vaping side effects. Overall, results suggest that a physician-lead, virtual curriculum can effectively relay information about the risks of e-cigarette use in an adolescent population.
Hand-On: A Prospective Cohort Study of Direct Observation of I-PASS Handoffs in Pediatric Interns
Nicole Drawbridge M.D., Chris Daly M.D., Ryan Wolf M.D., Whitney Browning M.D., Rebecca Swan M.D.
Assessment of Performance of Non-Technical Skillsby Medical Students in Simulated Scenarios
Jaycelyn R. Holland MD; Donald H. Arnold MD, MPH; Holly R. Hanson MD, MS; Barbara J. Solomon MD; Nicholas E. Jones MD; Tucker W. Anderson MD; Wu Gong MD, MS; Christopher J. Lindsell PhD; Travis W. Crook MD; Daisy A. Ciener MD, MS
Caring for patients in an emergency requires non-technical skills such as teamwork, communication, and task management. However, medical training has traditionally focused on technical skills and discrete medical knowledge. Simulation has been used to train residents, fellows, and attendings in non-technical skills but not medical students. The Behaviorally Anchored Rating Scale (BARS) is a validated scoring system for non-technical skills that is simple and requires two hours of training. It has never been studied in the medical student population. Our objective was to determine the inter- and intra-rater reliability of the BARS when used in the medical student population to assess non-technical skills. Study Design We created a simulation curriculum for medical students during their core pediatric clerkship at a single medical school site. Students performed in teams caring for patients in simulated pediatric emergencies. The academic year is broken into five blocks. While we planned to complete the simulation curriculum in blocks 1, 3, and 5 to sample students throughout the academic year, block 5 was cancelled due to the coronavirus pandemic. Three content experts were trained to use the BARS. Experts reviewed video recordings of the student-performed simulations and assigned BARS scores for 4 performance components (Situational Awareness, Decision-Making, Communication, and Teamwork) for the team leader and for the team as a whole. Krippendorff’s alpha with ordinal difference was calculated for the liability measurement of components of the BARS. Results 30 medical students participated and had recordings available for review. Inter- and intra-rater reliability for each performance score were, respectively: Individual Situational Awareness (0.488, 0.638), Individual Decision-Making (0.529, 0.691), Individual Communication (0.347, 0.473), Individual Teamwork (0.414, 0.466), Team Situational Awareness (0.450, 0.593), Team Decision-Making (0.423, 0.703), Team Communication (0.256, 0.517), and Team Teamwork (0.415, 0.490). None of the components met criteria for good inter- or intra-rater reliability. Conclusion This pilot study with a small number of subjects demonstrated limited reliability when assessing medical students during their core pediatric clerkship. Given the unique needs of this population, a modified or new objective scoring system for assessing non-technical skills may be needed for medical students.
Secondary Prophylaxis of Rheumatic Heart Disease (RHD) in Ethiopia
Wubishet Belay, Azene Dessie, Hayat Ahmed, Etsegenet Gedlu, Abinet Mariyo, Abdulkadir Shehibo, Zemene Tigabu, Muktar H. Aliyu, Jonathan Soslow
Methods A multi-center, cross-sectional study was conducted. Children aged 3-17 years with an echocardiogram-based diagnosis of RHD were included. Those with congenital heart disease and a recent diagnosis of RHD (<1 year) were excluded. Good adherence was defined as 80% completion of at least 80% of prophylaxis prescriptions within the previous year. The primary outcome measure was adherence to secondary prophylaxis of RHD, expressed as a proportion. Covariates include patient socio-demographics (eg age, sex, household size, household income, rural/urban residence), type and severity of RHD, history of recurrence of ARF. Students’ chi-square test and t-test for difference in means were used to assess for differences among categorical and continuous variables respectively. Factors independently associated with adherence were determined using multivariate logistic regression, with adherence to RHD classified as a binary variable (yes/no). Odds ratio (OR) and confidence intervals (CI) were reported. A P-value <0.05 was considered statistically significant.
Results: A total of 264 patients were included. The mean age was 13±2.6 years. The majority were females (54%) and resided in rural areas (62%). Severe aortic/mitral disease was seen in 75% of the cases. Intramuscular benzathine penicillin (BPG) (76%) and oral Amoxicillin (24%) were the prophylaxis of choice. About 24% of those on amoxicillin and 13% of those on BPG met the criteria for poor adherence (P=0.04). Participants with good adherence were mostly females (P=0.04), younger (12.8±2.7 vs 13.7±2 years, P=0.04), and had a shorter mean duration of prophylaxis than those with poor adherence (48.7 months ± 31 vs. 59.2 months ± 34, respectively, P=0.02). Running out of medication before their clinic visit (38%), avoiding travel due to the COVID-19 pandemic (26%), and missed follow-up visits (9.5%) were the 3 most common reasons for missing prophylaxis. Recurrence was higher in participants on oral amoxicillin compared to those on BPG (37.1% vs 17.1%, P<0.001). The rate of recurrence was also higher in participants with poor adherence than in those with good adherence (45.2% vs. 19.3%, respectively, P<0.01). Type of prophylaxis (OR 0.4, P=0.012), severe valvular disease (OR=8.7, P=0.04), and sex (OR=2.16, P=0.03) as independent predictors of poor adherence
Conclusion: Poor adherence is prevalent in Ethiopian children with RHD. Amoxicillin is suboptimal prophylaxis associated with a high rate of low adherence and recurrence.
MULTI-DRUG RESISTANT INFECTIONS AMONG VERY LOW BIRTH WEIGHT INFANTS WITH LATE-ONSET SEPSIS IN SOUTH AFRICA
Genesis Licona, MD, Troy D. Moon, MD, MPH, Ritu Banerjee, PhD, MD, Daynia Ballot, MBBCH, FCPaeds SA, PhD, Gustavo Amorim, PhD, Rossella Bandini, Hendrik Weitkamp, MD
Genesis Licona, MD1, Troy D. Moon, MD, MPH 2, Ritu Banerjee, PhD, MD2
Daynia Ballot, MBBCH, FCPaeds SA, PhD3, Gustavo Amorim, PhD4, Hendrik Weitkamp, MD1
1Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center
2Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center
3Division of Neonatology, Department of Pediatrics, Charlotte Maxeke Academic Hospital, University of the Witwatersrand
4Department of Biostatistics, Vanderbilt University Medical Center
Objective: The majority of neonatal deaths occur in the first week of life, with the highest risk of death on the first day of life. Neonatal mortality rates (NMR) vary throughout the world. Neonatal sepsis accounts for ~30% of neonatal mortality, with very low birth weight (VLBW) neonates (birth weight <1500 g) disproportionately affected. NMR in South Africa is 10.7 deaths per 1000 live births compared to 3.5 in the United States of America with an overall incidence of neonatal sepsis falling between 8.5-10%, with late-onset sepsis (LOS) accounting for most (83.7%) infections in South Africa. The mortality rate of LOS was found to vary between 19.7-22.5%, according to available South African data. Antibiotic use, either empiric, or targeted for proven infection, can lead to an increasing number of multi-drug resistant organisms (MDRO’s) in neonatal intensive care units (NICUs) worldwide. MDRO type and prevalence vary across institutions. MDROs have proven to be a global public health emergency and threat to the vulnerable neonatal population globally. This study aims to characterize the prevalence and incidence of LOS caused by select MDROs and identify maternal and neonatal risk factors associated with increased mortality among a cohort of VLBW infants with LOS at an academic neonatal unit in South Africa. We hypothesize that the incidence of late-onset sepsis caused by MDROs in VLBW infants is increasing and that VLBW infants with late-onset sepsis caused by MDRO vs non-MDRO are at higher risk of mortality.
Study Design: This will be a retrospective cohort study of VLBW infants treated for LOS (defined as growth of a bacterial pathogen from a blood or cerebrospinal fluid (CSF) culture greater than 72 hours after birth) that were admitted to Charlotte Maxeke Academic Hospital between 2015 to 2020. Maternal and neonatal data collected in REDCap (UL1 TR000445 from NCATS/NIH ) will be analyzed from an existing neonatal database using multivariable logistic regression to determine associations between demographics or exposures and LOS with MDROs (multi-drug resistant organism MRSA; carbapenem-resistant Enterobacterales; ESBL-producing E. coli or Klebsiella and any gram-negative with non-susceptibility to at least 1 drug in 3 or more antimicrobial classes).
Conclusion: Multi-drug resistant infections are a public health emergency worldwide. It is critical to monitor antimicrobial consumption and resistance patterns to optimize local antimicrobial usage.
Development and Validation of a Neonatal Intensive Care Unit Discharge Model for Preterm Infants
Kevin Patel, MD, Dan France, PhD, MPH, Mhd, Wael Alrifai, MD, MS, S Trent Rosenbloom, MD, MPH
Our objective is to develop and validate a Neonatal Discharge Model (NDM) that uses clinical features within the Electronic Health Record (EHR) to identify patients within five days of discharge.
This study is a single-center cohort analysis on preterm neonates with gestational ages between 28 and 36 weeks discharged alive from a level 4 NICU between 2019 and 2020. Patients will be excluded if they require durable medical equipment (DME). During model development, we obtain daily flowsheet data via Clarity, Epic’s relational database, through Vanderbilit Clinical Informatics Center. We will build a logistic regression model that will determine the probability of a patient’s discharge within five days given the clinical features of a given day. We will then use a receiver operating characteristic (ROC) curve to evaluate various threholds and select the one with ideal sensitivity and specificity. NDM validation will occur prospectively on patients admitted over a period of 3 months. The same exclusion criteria apply during model validation. During Model validation, we will integrate the NDM into eStar (Epic) via a workbench report. Daily probabilities of discharge within 5 days will be collected. These patients will be followed until discharge to assess NDM performance.
Non-clinical drivers of antimicrobial prescribing for pediatric patients in diverse ambulatory settings: a qualitative assessment
Hillary Spencer, MD, MPH; Sophie Katz, MD, MPH; Carolyn Audet, PhD, MSc; Ritu Banerjee, MD, PhD
Comparison of the Prevalence of Pediatric Poisonings Before, During and After COVID-19 Shelter-in-Place
T. Christy Hallett, MD, Allen M. Hallett, MS, and Rebecca E. Bruccoleri, MD
Direct-to-Patient Telehealth Equity: Reaching English and Non-English-Speaking Pediatric Populations in Primary Care
Shani Jones, MD, Sara Van Driest, MD, PhD, Evan Sommer, Maggie Brown, Kathryn Carlson, MD, Aida Yared, MD, Adriana Bialostozky, MD, Kemberlee Bonnet, MA, David Schlundt PhD, Shari Barkin, MD, MSHS
Study Design: We conducted acute and well-child telehealth visits from April to May 2020 at an academic pediatric primary care clinic (80% Medicaid-insured, 40% non-English-speaking). Telehealth visits were scheduled using the clinic’s patient-facing portal or other platforms (WhatsApp, FaceTime, Zoom) based on patient preference. Trained providers included pediatric residents and faculty members (70% faculty providers in April and 92% faculty in May). For quantitative data, providers completed an electronic survey describing platform and device used, interpreter use, ease of process, and video image quality. Group comparisons tested differences in telehealth visits by language spoken. For qualitative data, an iterative inductive/deductive approach informed coding categories extracted from free-text options on patient feedback and provider observations.
Results: Data from 258 telehealth visits (62% well-child and 38% acute visits) were analyzed. Most (80.6%) were in English, with the remaining in Spanish (14.7%), Arabic (3.5%), or other languages (1.2%). Most (77%) visits were conducted with patients using a mobile phone. English speakers (60.8%) were more likely than non-English speakers (26.5%) to use the clinic’s patient portal (p<0.001). English-speaking patient encounters vs. Non-English experienced better process ease (85.6% vs. 63.3%; p<0.001) and video quality (81.8% vs. 49.0%; p<0.001). WCC visits were conducted in English significantly more often than acute visits were (91.3% of WCCs visits in English vs. 64.3% of acute visits in English; p<0.001). A qualitative framework emerged including family call environment, technology process and experience, value added, and barriers.
Conclusions: There were differences by language in telehealth use, communication platform, process ease, and video quality. Expanding direct-to-patient telehealth without worsening the health equity gap requires attention to the use of mobile phones as well as cultural and language preferences.
Physician Attitudes and Counseling Practices for Neonate with Trisomy 18
Caitlin Jacowski, MD1, Catherine M. Hammack-Aviran, JD, MA2, Ellen Wright Clayton, MD, JD2 , Jessica Turnbull, MD, MA2,3, Uchenna Anani, MD1,2
The Ethical Decision-Making Climate and Moral Distress in the Pediatric Intensive Care Unit
Emily Deaton, MD, MS and Jessica Turnbull, MD, MA
Demographic Factors and Transition Timing Predict Successful Transition to Adult Care in Emerging Adults with Type 1 Diabetes.
Daniel R. Tilden, M.D., Ashley H Shoemaker, M.D., Sarah S. Jaser Ph. D.
Clinicians’ Perspectives on Integrating a Parenting Assessment Tool into the Well Child Visit
Amber Cooke MD, Kate Carlson MD, Merrill Stoppelbein APRN, Seth Scholer MD
Objective: To determine clinicians’ perspectives on integrating the QPA into the well child visit.
Design/Methods: In our clinic serving low income families, we routinely administer the QPA as part of the 15 and 30 month visits. The QPA takes approximately 1 minute for parents to complete. Clinicians were trained to interpret and respond to the QPA with a 15 minute presentation. For parents who were given a QPA as part of the well child visit, clinicians were invited to complete a survey focused on their perspectives on integrating the QPA into the visit. Key measures were 1) time needed for the clinician to review the QPA, 2) whether the QPA increased clinicians' objectivity (i.e. make fewer assumptions) in determining the level of support needed for the caregivers, 3) whether the QPA affected communications with the caregiver about parenting, and 3) whether the QPA added value to the well child visit.
Results: 172 surveys were completed by resident physicians (33%), nurse practitioners (33%), and attending physicians (33%). Most QPA reviews (130/172; 76%) took 1 minute or less; 17% took 1-2 minutes and 7% took 3-5 minutes. For most QPA reviews, the clinician reported that the QPA increased objectivity to determine the level of parenting support needed (64%), facilitated communication about parenting (74%), and added value to the visit (69%).
Conclusion: A parenting assessment, when integrated into the 15 and 30 month well child visit, can be reviewed by clinicians with parents in less than three minutes for over 80% of encounters, can help clinicians offer higher precision parenting support, and can facilitate parent/clinician discussions about healthy discipline strategies. Our results have implications for mitigating ACEs and enhancing the pediatric primary care visit.
WORKING IN THE PEDIATRIC CARDIAC INTENSIVE CARE UNIT: ARE YOU FEELING UNCOMFORTABLE AND DOES SIMULATION HELP?
Kathy S. Mendieta, Kelly A. Craighead, Isaura Diaz
Hangry No More: Decreasing Pre-Procedural Fasting Time for Hospitalized Children
Alison R. Carroll, M.D., Allison McCoy, Ph.D., MS. Marni Krehnbrink, M.D., Lauren Starnes, M.D., M.Ed., Patricia A. Frost, M.D., and David P. Johnson, M.D.
Study Design: We included all children admitted to our hospital medicine service with an NPO (nil per os) order associated with a procedure requiring anesthesia from November 2, 2017 to the present. Children with fasting times <2 hours or >24 hours were excluded. The Model for Improvement was used to test interventions based on 5 key drivers aimed at reducing fasting times (Figure 1). Interventions included nursing and provider education on hospital NPO guidelines, use of standardized language (SmartPhrase) in the electronic health record (EHR) NPO order (Figure 2), and a change to the NPO order format hospital-wide (Figure 3). We used statistical process control charts to study all measures. The primary measure was the average time from documented clear liquid fasting end time to anesthesia start time. The process measure was the percent of NPO orders that included a documented clear liquid fasting end time. Balancing measures were aspiration events and case delays/cancellations due to pre-procedural fasting violations.
Results: Baseline data from November 2017 to September 2019 included 579 NPO/anesthesia events revealing an average NPO time of 10 hours 13 minutes. Shortly after implementation of a SmartPhrase in the EHR NPO order, there was special cause variation resulting in a centerline shift from a mean of 10 hours 13 minutes to 6 hours 36 minutes (Figure 4) as well as an increase in the process measure of percent of orders with a clear liquid fasting end time to 65.9% (Figure 5). There have been two NPO violations during the intervention period.
Conclusion: Creating and sharing a SmartPhrase was associated with a simultaneous improvement in our primary outcome and process measures reducing clear liquid fasting times. We hypothesize that a recent higher reliability intervention—a change to the hospital-wide EHR NPO order—will be associated with a further reduction in pre-procedural fasting time for all hospitalized children.