These posters have been presented at meetings in Children's Mercy and around the world. They represent research that was done at the time they were created, and may not represent medical knowledge or practice as it exists at the time viewers access these posters.>
Jennifer A. Lyon, Angie Knackstedt, Barbra Rudder, Mamta Reddy MD, and Courtney R. Butler
BACKGROUND: A multidisciplinary group at Children's Mercy Kansas City applied for and received the NNLM MCR's Immersive Workshop Grant in December, 2017, and used the funding to organize and host a two-day immersive, interprofessional workshop in April, 2018, that 1) brought together health literacy-invested groups and individuals within the Kansas City community to learn about health literacy including cultural, language, numeracy and digital inclusion factors; and 2) provided specialized training to targeted CM participants to improve the provision of bedside health information to patients and caregivers. Objectives included: increasing community-wide collaboration, sharing resources, encouraging participants to become change agents, and strategizing organizational initiatives. DESCRIPTION: The project team consisted of 2 librarians, a practicing physician, a child life specialist, and a nurse educator specializing in equity and diversity; all were past or present members of the institution's Health Literacy Committee. Day One, at the Public Library, was open to the community. Over 25 organizations involved with health literacy and health equity were invited to contribute speakers and participants. Dr. Ruth Parker of Emory University delivered two 'keynote' lectures. Other speakers represented an adult literacy volunteer agency, the Public Library, and an immigration support organization. Day Two was held internally, focusing on hospital employees professionally invested in promoting health literacy practices in patient care. Additional training on institution-specific resources was supplemented by interactive, hands-on practice sessions and brainstorming exercises intended to develop internal health literacy pilot projects, with encouragement to reconnect with the community organizations. CONCLUSIONS: Day One had 73 attendees (28% from the community). Day Two had 60 attendees. All participants were fully engaged throughout, including interactive brainstorming activities. All informal comments to organizers were positive and the planning team has received requests to repeat the workshop in the future. A survey was sent to all attendees (67-69% response rates). On a Likert scale from 1-5, the means on questions regarding health literacy awareness, motivation to take action, and increased knowledge of resources and collaboration opportunities ranged from 4.88-4.95 for both days. Internal projects are being developed and communication with external groups has steadily increased.
Benjamin A. Matta, Uri S. Alon, Tarak Srivastava, Bradley A. Warady, and Darcy Weidemann
This study's objective was to determine the effect of antihypertensive dose on hypertension status in children with chronic kidney disease. This was the first quantitative analysis of antihypertensive dose expressed as a newly developed measure, cDDI, and is relationship with hypertension status in children with CKD.
Practice Variations in Sedated Echocardiography and Impact on Repeat Echocardiography in Non-Refractory Kawasaki Disease
Nicholas Clark, Troy Richardson, Jennifer E. Schuster, Anitha Parthiban, and Henry T. Puls
This study discovered significant variation among children's hospitals in the use of sedated echocardiiography for children <30 months of age with non-refractory Kawasaki disease prior to the American Heart Association 2017 Kawasake disease guideline update. Consideration should be given to performing sedated echocardiography as it may reduce the need for repeat echos without impacting length of stay or total>costs.
Nicholas Clark, Julia Simmons, Angela Etzenhouser, Troy Richardson, Patrick Brady, and Eugenia K. Pallotto
Describes a quality improvement project to increase two-way discharge communication between pediatric hospitalists and primary care providers from 7% to >80% within 18 months.
Weighted Pathway Genetic Load Analysis of Hyperbilirubinemic Infants Indicates a Potential Genetic Component for Susceptibility to Bilirubin Neurotoxicity
Sean M. Riordan, Jean-Baptiste LePichon, Steven Shapiro, John Cowden, Monica VillaGullen, Laurence Thielemans, Dina Villanueva Garcia, and Jesus Aguirre-Hernandez
Severe kernicterus spectrum disorder (KSD) is described as motor and auditory deficits resulting from brain damage caused by hyperbilirubinemia. The severity of HB does not always predict the severity of injury. The lack of a strong monogenetic link to susceptibility suggests bilirubin-induced brain damage may be due to impaired bilirubin response pathways. This poster describes work to use a modified pathway genetic load (mPGL) score method to perform a targeted genetic analysis of whole exome data from patients with various degrees of neonatal HB, with an ultimate goal of developing a neonatal screen to susceptibiltiy to bilirubin neurotoxicity.
Sean M. Riordan, Jean-Baptiste LePichon, Steven Shapiro, Tina Slusher, Fatima Abdullahi, Hafsat M. Suleiman, Victor C. Pam, Mamu B. Samuel, Christopher S. Yilgwan, Christian Isichei, and Idris Y. Mohammed
Acute bilirubin encephalopathy (ABE) and kernicterus spectrum disorder (KSD) have become relatively uncommon in high income countries but remain a major cause of morbidity and mortality in low- and middle-income countries. To better understand the relationship between free (Bf) and total (TB) bilirubin levels and the development of ABE and KSD we followed infants born in three large tertiary centers in northern and central Nigeria (Jos, Kano and Zaria).
Isa Abdulkadir, Tina Slusher, Fidelia Bode-Thomas, Sean Riordan, Jean-Baptiste LePichon, Laila Hassan, Shehu Abdullahi, Akinyemi Ofakunrin, Stephen Oguche, Steven Shapiro, and William Ogala
This poster presents a collaboration between a group of scientists in Nigeria and the USA in developing a genomic research project and the solutions adopted in tackling the ethical implications and partnership equity and ownership of such a project.
Rylee Ainge, Mackenzie Flaws, Natalie Heim, Emily Herndon, Hayley Norris, and Amy L. Scott
Describes experience providing care at the Botswana-Baylor Children's Center of Excellence in Gabarone, Botswana and the Princess Marina Hospital.
Describes her experience working in the Philippine General Hospital/University of the Philippines providing care in the pediatric ICU, neonatal ICU, and emergency department.
Examining Nurse Resiliency & a Mindfulness-Based Stress Reduction Intervention to Prevent Nurse Burnout
Nurses continually give of themselves at work, as well as outside of work. This results in extensive stress, physiological distress, and ultimately burnout for individuals in the nursing profession. Nurses that work in high-stress environments, such as critical care, pediatrics, and oncology, are at a significantly increased risk of manifesting physical and psychological symptoms of burnout syndrome, compassion fatigue, and post-traumatic stress disorder (PTSD). Many of these factors are leading to nurses leaving the profession prematurely, resulting in significantly high turnover rates. High burnout and turnover rates of nurses result in the lack of adequate nursing staff in hospitals, which in turn results in the inadequate ability to provide safe and effective care to patients. Resilience is a topic that has gained much discussion in recent years surrounding the significant burdens nurses are experiencing. Nurses with resilience exhibit a heightened awareness, internal stability, and flexibility that allow them to navigate high-stress situations. The goal of resilience training and education is to enable nurses to respond to clinically challenging situations in ways that will protect them against detrimental consequences. Mindfulness based stress reduction (MBSR) has gained significant headway in recent years as a valuable, evidence based intervention to increase resiliency in nurses, improve job satisfaction, and reduce burnout. The purpose of this quality improvement project was to implement a MBSR course for nursing staff to improve nurse resiliency in a mid-western freestanding Children’s hospital. This project examined nurse resiliency pre-intervention, and post-intervention utilizing the Connor-Davidson Resilience Scale, as well as compassion fatigue, compassion satisfaction, burnout, and secondary traumatic stress pre-intervention, and post-intervention using the Professional Quality of Life scale. Results of the project indicate that resilience scores improved, at a statistically significant level, from pre-intervention to post-intervention.
Describes a global health learning experience with Baylor International Pediatric AIDS Initiative in Swaziland.
Describes a global health learning experience
Jeremy Jennings and Jennifer Watts
Describes global health learning experience providing ambulatory care in Cambodia.
Keith J. Martin
Describes a global health learning experience working in the Philippine Children's Medical Center in Quezon City, Metro Manila, Philippines.
Laura Plencner, Matthew Hall, Molly Krager, Henry T. Puls, Jessica L. Markham, Ellen Kerns, and Jessica L. Bettenhausen
Retrospective cross-sectional study describes differences in hospitalization rates for children based upon their residence within a food desert and describes any differences among reasons for hospitalization.
Laura M. Plencner, Margo Quiriconi, Sarah Sentmore, and Molly Krager
The Summer Food Service Program was established to ensure that children continue to receive adequate nutrition while school is out. This poster describes how the program was implemented in the Children's Mercy Kansas City healthcare system from 2016-2018.
Irina G. Trifonova
Describes a global health learning experience in which a Russian-trained pediatrician completed a fellowship at Children's Mercy Kansas City and spent time at the City Children's Hospital #3 in Cheboksary, Russia to compare care models for children with medical complexity in Russia and the USA.
Describes a global health learning experience at the Botswana Baylor Center of Excellence with emphasis on treating pediatric HIV/AIDS patients.
Richard K. Ogden Jr., Jerame Hill, and Sam Abdelghany
Erin Fecske, Paul Glasier, Lines Vargas Collado, and Elizabeth Rende
Describes the use of the Neurological Disorders Depression Inventory-Epilepsy-Youth (NDDI-E-Y) in adolescent patients in a comprehensive epilepsy center to identify patients who need referral for mental health care.
Melissa Beals, Robert J. Krumsick, C. Clinton Frazee III, Lindsey J. Haldiman, and Uttam Garg
Oxcarbazepine is a derivative of carbamazepine that is used primarily in the treatment of epilepsy, and experimentally as a mood-stabilizer in adjunctive therapy for the treatment of bipolar disorder. Oxcarbazepine is converted through oxidation to its pharmacologically active metabolite 10-OH-Carbazepine, which is thought to be responsible for most of the anticonvulsant action of the drug. Adverse effects of oxcarbazepine are generally dose-dependent and may include fatigue, somnolence, dizziness, diplopia, nystagmus, and ataxia. Additive sedative effects have been noted when oxcarbazepine is used in combination with other CNS depressionproducing medications. Furthermore, oxcarbazepine and 10-OH-Carbazepine are powerful CYP2C19 inhibitors, potentially increasing the plasma concentration and pharmacological response of CYP2C19 substrates such as diazepam. The therapeutic range for oxcarbazepine is based on the metabolite and extends from 6-35 μg/mL. Toxicity has been reported with 10-OH-Carbazepine levels as low as 65 μg/mL, and one fatality has been documented with a 10-OH-Carbazepine concentration of 92 μg/mL. Hydrocodone is a narcotic analgesic that undergoes demethylation and reduction to produce several pharmacologically active metabolites, including hydromorphone, norhydrocodone, and dihydrocodeine (6-α-hydrocodol), which contribute to its efficacy. Hydrocodone toxicity may be characterized by respiratory depression, drowsiness, and coma. Therapeutic blood and plasma concentrations of hydrocodone typically range from 10-50 ng/mL, while levels greater than 100 ng/mL are considered toxic, and concentrations exceeding 200 ng/mL can be potentially fatal. Diazepam is a benzodiazepine known for its efficacy and rapid onset. Therapeutic ranges of diazepam and its metabolite nordiazepam in blood and plasma measure between 200-2500 ng/mL. Diazepam toxicity may result in drowsiness, weakness, ataxia, and coma; however, serious and fatal effects are uncommon with diazepam if used singularly. Most terminal adverse events associated with diazepam are the result of interaction or combination with other drugs, especially CNS depressants.
To present a case of a polysubstance related suicide involving the synergistic effect of toxic concentrations of oxcarbazepine and hydrocodone in combination with the presence of diazepam. To report the highest blood concentration of 10-OH-Carbazepine found in literature for a drug-related death investigation.
Presented in this case is a 67-year-old female with a history of depression, psychiatric hospitalization, and previous suicide attempts. The decedent was found lying supine in bed with a bottle of hydrocodone in one hand and a can of soda in the other, next to a suicide note. Several other prescription medications, including oxcarbazepine, gabapentin, diazepam, quetiapine, tizanidine, and lorazepam were found at the scene.
Postmortem heart blood, femoral blood, urine, vitreous fluid, gastric contents, and liver and brain tissue were submitted for toxicological analysis. Routine screening of heart blood was performed using Enzyme Multiplied Immunoassay Technique (EMIT) and liquid-liquid alkaline extraction followed by gas chromatography/mass spectrometry (GC/MS) analysis. 10-OH-Carbazepine as well as hydrocodone and its metabolites were quantified in femoral blood by an external laboratory using liquid chromatography/tandem mass spectrometry (LC-MS/MS). Diazepam and nordiazepam quantitation was performed on heart blood using high performance liquid chromatography (HPLC).
The most significant finding in this case is the 10-OH-Carbazepine concentration of 180 μg/mL, which is greater than the highest known fatal level of 92 μg/mL. The cause of death in this case was ruled oxcarbazepine and hydrocodone intoxication with diazepam use,
Alannah K. Yoder, Richard K. Ogden Jr., Ingrid A. Larson, and Emily J. Goodwin
Children with medical complexity require unique care, specialized attention, and a dedicated team to meet the needs of the patient & caregivers. Drug-therapy related problems in complex, chronic conditions influence financial, institutional, and patient outcomes. The addition of a pharmacist allows for collaboration and delivery of comprehensive medication management in order to provide value-added medication services to optimize complex therapeutic regimens and patient outcomes through evidence-based practice, medication adherence, medication use coordination, and medication safety processes.
Our program provides a pediatric medical home for hundreds of children with medical complexity. Families are cared for by a comprehensive medical team, including a clinical pharmacist. The pharmacist is available for all appointments and meets with patients and caregivers at the beginning of clinic visits. The pharmacist’s initiative to improve patient care is provided through multiple services which include: (1) comprehensive medication reconciliation through history provided by caregiver, outpatient pharmacy review, and chart review of specialty teams; (2) adverse drug assessment; (3) systemic drug-utilization review of each medication (drug-disease contraindication, drug-drug interaction, drug-patient precaution, dosing, duration of drug treatment, over and/or underutilization, drug dosage for modification, adherence concerns, and determination if additional monitoring is warranted); (4) patient education and development of personal, family-friendly medication lists; and (5) coordination of care between inpatient admissions, specialty/consulting services, home healthcare, and prior authorization needs.
The integration of a pharmacist in a pediatric medical home for children with medical complexity and childhood-onset disabilities allows for innovation and interdisciplinary collaboration to provide comprehensive medication management. Incorporation of family education and tangible medication plans promotes safe and consistent medication practices. Further studies describing the qualitative and quantitative impact on patient outcomes will be conducted at our institution.
Review of Karyotypic Data from Low Grade Glial Brain Tumors, Specifically Pilocytic Astrocytomas, and Correlation of Genetic Aberrations with Tumor Recurrence.
Linda D. Cooley, Scott C. Smith, Lisa Warren, Melissa Gener, Kevin Ginn, and John Herriges
Abstract: Brain tumors are the most common solid tumor of childhood. Approximately 50% of pediatric CNS tumors are low grade gliomas (WHO grade I or II) and Pilocytic astrocytoma (PA) is the most common accounting for 33% of all gliomas in children 0-14 years and ~18% of all childhood brain tumors. Prognosis with this slow-growing tumor is excellent; 10 year overall survival of ~95%. However, event free survival averages ~50%. Patient age and extent of tumor resection are key prognostic factors; tumor location and size impact resection and outcome. Histopathological features indicate PA is a benign tumor and rarely are anaplastic features of malignancy present. This study sought to determine if chromosomal aberrations correlate with increased risk of tumor recurrence. Observation shows that while the majority of PA have a normal karyotype, a portion have highly abnormal karyotypes; the clinical significance of which is unclear. Methods: Pathology archives were queried for PA between mid-2008 and mid- 2017. Review included chromosome, FISH, microarray, molecular results, cytogenetic methods, histopathology, tumor location, patient age, extent of surgical resection, chemotherapy, radiotherapy, and outcome. Karyotypes were defined as “aberrant” if there were multiple bizarre chromosome abnormalities, multiple telomeric association (tas) figures or translocations, or multiple dicentric chromosomes. Routine cell culture methods were used with mechanical +/- enzymatic disaggregation, alpha-MEM medium, and monolayer coverslip cultures with harvest as soon as feasible to capture metaphase cells. Results: Of 64 cultured PA, 4 failed to grow. Karyotypes were normal (n=32), simple (n=3), hyperdiploid (n=12), or aberrant (n=13). Four patients had a second tumor resection; 2 had aberrant and 2 had normal karyotypes on the initial and repeat studies. Of the 13 patient tumors with aberrant karyotypes, 6 tumors (CMH cases 1-5) demonstrated tas, dicentrics, subclones, etc., and two (CMH cases 6, 7) had multiple cells with an excess of aberrant chromosomes. Four tumors (CMH cases 8-13 – not shown) had a normal karyotype with one or two highly aberrant cells; of these, one patient with two resections (CMH cases 11 & 12) showed two highly aberrant cells on both the initial and second study. Discussion: Highly aberrant karyotypes are unexpected in benign tumors. PA, is a histologically benign tumor with ~95% 10 year overall survival. Repeatedly finding highly aberrant karyotypes in some of these tumors begs the question of clinical significance. How should these karyotypes be interpreted? Finding the abnormalities in tumors resected twice suggests an ongoing cellular/biologic process specific to that tumor tissue. The repeat finding of tas and dicentrics suggests a role for telomere dysfunction in these tumors. This is consistent with up-regulation of TRF1 and TRF2 (TTAGGG repeat-binding factors) occurring in the early stages of LGG carcinogenesis, which is characterized by short telomeres, genomic instability, low proliferative rate and prolonged life span (1). Limitations of the study: Data are limited – few patients, inconsistent FISH, microarray and molecular studies were done; no sequence analysis. Multiple factors play a role in patient outcome including tumor location and resectability. Conclusions: Additional cases, additional follow-up, additional genomic analyses are needed. Next step: WES of rearranged cases is planned.
Facilitating the everyday steward: Impact of mandatory antimicrobial indication/duration and a 48 hour time out
Ann L. Wirtz, Alaina N. Burns, Brian R. Lee, Tammy Frank, Laura Fitzmaurice, Richard Ogden, Brian O'Neal, and Jennifer Goldman
Introduction: Required indication, duration, and a 48-hour antimicrobial timeout are an integral part of antimicrobial stewardship standards; however, limited data are available to demonstrate an effect on antimicrobial utilization and antimicrobial stewardship practice. Therefore, we evaluated the impact of mandatory declared indication/duration along with a pharmacy-driven 48-hour timeout on antimicrobial utilization and antimicrobial stewardship interventions.
Methods: We performed a retrospective evaluation of ASP interventions and antimicrobial use following implementation of mandatory antimicrobial indication/duration at the point of computerized physician order entry (CPOE). A pharmacist-driven 48-hour antimicrobial timeout was introduced on the same date. This study was conducted at Children’s Mercy Kansas City, a 367-bed freestanding pediatric hospital servicing the Kansas City Metro Area and beyond. Data were collected from February 1, 2016 to January 31, 2018. A pre and post comparison was performed; interventions were implemented hospital-wide on February 14, 2017. ASP intervention rates were measured. Days of therapy (DOT) per 1000 patient days of antibiotics were also evaluated. Poisson models were utilized to compare DOT rates pre- and post-implementation, and seasonal decomposition analyses were performed to account for seasonal variability.
Results: A significant decrease in DOT rates was observed in non-ASP monitored antibiotics post-implementation, including cefazolin (39.7 to 36.9; p
Conclusions: Implementation of additional stewardship practices, including mandatory antimicrobial indication/ duration and a pharmacist-driven 48-hour timeout, resulted in a decrease in the use of antimicrobials, including those not monitored by our ASP. These efforts augmented, but did not replace existing stewardship efforts. These results support initiatives highlighted by national organizations to minimize unnecessary antimicrobial use through ASP.