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  Rates of Positive Suicide Screens among the Emergency, Inpatient and Outpatient Clinics at a Tertiary Care Children’s Hospital

  Fajar Raza, Hung-Wen Yeh, John Lantos, Mark Connelly, and Shayla Sullivant

  Background: Prior research has suggested that rates and acuity of suicidality are elevated among patients seen in EDs and in certain clinics. However, the occurrence and severity of suicide risk has been rarely studied in the pediatric clinic populations due in part to unsystematic screening. We examined suicidality across different pediatric clinical care settings based on data from our newly implemented hospital-wide suicide risk screening program.
  
  
  Objective: To determine a) which patient populations presented with the highest rates of suicidality; and b) the percentage of patients who had current thoughts of suicide and were thus deemed “acute.”
  
  
  Design/Methods: We conducted a retrospective analysis of the clinical data repository. Adolescents were screened for suicide risk between Feb 2019 and Jan 2020. Patients were eligible for suicide risk screening if they were >12 years old and had a medical visit in the inpatient (IP), emergency (ED), urgent care (UC), or outpatient (OP) clinics of a dedicated pediatric hospital in the midwest. We used the 4-question ASQ (Ask Suicide-Screening Questions) by which a positive response to any of the 4 questions was considered a positive screen. Among positives, those who gave a positive response to question 5 (“are you having thoughts of killing yourself right now?”) were classified as “acute risk.”
  
  
  Results: Out of the 101,732 screenings completed during this time, 11,460 (11.3%) were positive, and 734 were at acute suicide risk. Overall positivity rates were highest among inpatients (18.6%), followed by the ED (18.0%), OP clinics (9.5%), and UC (8.8%). The highest rate of acute positives was found in the ED (3.1%), followed by IP (2.0%). The lowest rates of acute risk were observed for UC (0.2%) and OP clinics (0.1%). Among UC clinics, the highest rates of suicidality occurred in the Child Abuse Clinic (40.2%), followed by Adolescent Medicine (24.9%), Sleep and Teen Clinics (both 17.6%). The highest rate of acute suicide risk occurred in the Child Abuse Clinic (1.7%).
  
  Conclusion(s): Suicidality among pediatric patients is highest among adolescents seen in the inpatient unit and those seen in the ED. Some pediatric outpatient clinics also have high rates of suicidality but the rate of acuity appears to be lower in this setting relative to the inpatient and ED setting. Data on the acuity of risk and on the prevalence of acute risk in different clinical settings can be used to plan for allocation of mental health resources to follow-up on positive screens.

  Presented at the 2021 PAS Virtual Conference

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  Recurrent neonatal herpes simplex virus infection associated with IRF7 and UNC93B1 variants

  Venkatesh Sampath, Megan H. Tucker, Heather Menden, Sheng Xia, Wei Yu, and Nikita Raje

  Background: Neonatal herpes simplex virus (HSV) is a devastating disease with high mortality. In adults and children, genetic variants in the toll-like receptor 3 (TLR3) pathway increase susceptibility to herpes simplex encephalitis (HSE), but the genetic basis of susceptibility to neonatal HSV is unknown. We hypothesized that deleterious variants in the TLR3 pathway increased vulnerability to HSE in neonates. We investigated immunogenetic studies in an infant with neonatal skin, eye, mouth (SEM) HSV followed by HSE.
  
  
  Objective: To combine exome sequencing with in vivo and in vitro immune functional analysis to discover the immunogenetic basis of HSV vulnerability in proband.
  
  
  Design/Methods: The proband developed SEM HSV1 on day 7 of life and recovered fully with acyclovir. At 1 year of age he presented with seizures and was diagnosed with HSV1 HSE. Exome sequencing was performed to identify pathogenic genetic variants. An immune work up including peripheral blood monocyte (PBMC) functional TLR assay was done. Wild type and mutated alleles were transfected into THP1 monocyte cell line stably expressing an interferon regulatory factor 3 (IRF3) promoter-driven luciferase reporter. Poly(I:C) (1ug/mL), a TLR3 ligand, was used to stimulate THP1 for 24hr prior to luciferase assay and qRT-PCR for interferon (IFN) α and β gene expression.
  
  
  Results: We identified rare missense mutations in interferon regulatory factor 7 (IRF7) (p.Arg100Pro) and UNC-93 Homolog B1 (UNC93B1) (p.Pro404Ser) genes. Immune work up including CD4, CD8, NK cell, and immunoglobulins was normal, except for a total loss of PBMC cytokine response to TLR3 stimulation (Fig.1). Luciferase assays in THP1 showed dramatically reduced TLR3-driven IRF3 promoter activity in response to poly(I:C) with IRF7 and UNC93B1 variants (Fig. 2 & 3). Similarly, IFNα and IFNβ expression induced by poly(I:C) was enhanced by wild type IRF7 and UNC93B1 alleles, but strongly suppressed by mutant IRF7 and UNC93B1 alleles (Fig. 2 & 3). Combining the 2 mutant alleles compounded disruption of TLR3 signaling (Fig. 4).
  
  Conclusion(s): We identified 2 variants (IRF7, UNC93B1) that disrupted the TLR3-response to HSV in vitro and in vivo in an infant with recurrent HSV. This is the first report of human HSV disease associated with IRF7 mutation. Neonatal HSV may be a phenotype for immunodeficiency in the TLR3 pathway genes. Infants with severe neonatal HSV may warrant genetic screening to identify variants that increase recurrence risk, and prolonged acyclovir prophylaxis should be considered.

  Presented at the 2021 PAS Virtual Conference

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  Registration of newly diagnosed children with autism spectrum disorder and developmental disabilities at state regional offices

  Whitney Rolling and Rachel Goodson

  • In fiscal year 2020, 39,220 Missouri residents utilized developmental disability services through the Missouri Department of Mental Health.1 • Developmental disability services account for 53% of Missouri’s state mental health funding (about 1.3 billion dollars annually).

  • Physicians and psychologists are required for making eligible diagnoses, but registration for state support is patient dependent and can be perceived as an extensive paperwork process.

  • Project Goal: Measure and increase the percentage of eligible patients registered for their state mental health resource offices.

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  Response to dexamethasone predicts diagnosis of severe (type 2) bronchopulmonary dysplasia or death

  Christopher R. Nitkin, Keith Feldman, Alain Cuna, Alexandra Oschman, William E. Truog, Michael Norberg, Jane Taylor, and Tamorah Lewis

  Background: Bronchopulmonary dysplasia (BPD) is the most common respiratory morbidity after preterm birth but requires diagnosis at 36 weeks postmenstrual age (PMA). Dexamethasone is often used to treat infants at high-risk of BPD. The ability for earlier prediction of BPD, based on steroid response, could be useful as a surrogate marker for new therapies.
  
  
  Objective: To construct a model that predicts severe BPD or death at 36 weeks PMA based on clinical response to dexamethasone.
  
  
  Design/Methods: Retrospective chart review of preterm infants treated with dexamethasone between 2010-2020 at a Level IV NICU with data collected on demographics, age of steroid initiation, mode and level of ventilatory support during treatment, and pCO2 on day 1, 3, and 7 of steroid use. Highest mode of ventilation was assessed as either high frequency oscillatory ventilation, conventional invasive ventilation, or any form of non-invasive ventilatory support; while support level was represented by respiratory severity score (RSS = MAP*FiO2). BPD outcomes were defined according to the 2017 BPD Collaborative definition. The composite of mild, moderate, or severe (type 1) BPD was used as referent group to assess odds against the composite of severe (type 2) BPD or death.
  
  A regularized logistic model was fitted using the following variables: gestational age, sex, age of steroid initiation, baseline (Day 1) and percent change from baseline (Day 7 vs Day 1) in RSS and pCO2, and ventilator mode change from baseline. The resulting predicted probabilities were divided into quartiles to obtain a discrete risk level (level 1 to 4).
  
  
  Results: 94 infants were treated with dexamethasone prior to 36-week BPD assessment. A 10,000-iteration bootstrap was performed, and a risk score was predicted for infants not included in the resampled data at each iteration. The proportion of those with severe (type 2) BPD or death at each risk level were evaluated (Figure). For comparison, predictions were also made with a baseline model using only demographic data. Increasing risk category was well aligned with rising outcome incidence, increasing from ~20% of infants at level 1 to just over 55% of infants at level 4.
  
  Conclusion(s): The addition of changes in ventilatory parameters with dexamethasone improved BPD prediction compared to baseline demographics alone. Incorporating drug response phenotype into a BPD model may enable more rapid development of future therapeutics.

  Presented at the 2021 PAS Virtual Conference

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  Simulation Based Clinical Systems Testing in the Pediatric Emergency Department to Prepare for COVID-19 Pandemic

  Christopher S. Kennedy, Marc Sycip, Lisa Ell, and Shautonja Woods

  Background: The COVID-19 prompted pediatric emergency departments (PED) to prepare for a surge in patients. In response, guidelines developed represent “work as imagined” and may not reflect work as done. In situ simulations could identify gaps and help to mitigate errors. Simulation-based clinical systems tests (SbCSTs) can detect latent safety threats (LSTs) in systems design.
  
  
  Objective: Our aim was to use SbCSTs combined with rapid cycle training to test hospital system modifications for ED preparation. This method represenst a new application of SbCSTs. The research questions were in 2 frames: 1. Can rapidly deployed SbCSTs identify LSTs and recommendations for improvement and 2. Do providers consider rapid SbCSTs a way to improve preparedness?
  
  
  Design/Methods: The study took place in a PED and was approved by the IRB as non-human subject research. SbCST scenarios tested guidelines/job aids, equipment, and ways to mitigate exposure. Each case used “tipping-point”(s) to test workflow. Short scripted debriefs reviewed guidelines, staff input, and the simulation repeated. Participants evaluated the SbCST with a survey. Three sim staff collected observations on a standardized form for which process was tested, staff response, and LSTs identified.
  
  
  Results: Question 1. LST identification: From the 44 simulations, 64 staff identified 103 unique LSTs. LSTs were categorized as follows: Job Aids/tasks 37 (36%), Isolation Measures (PPE) 30 (29%), Communication/personnel: 18 (17.5%), and Equipment 18 (17.5%). Common LSTs identified: In the Job Aid category: simplify intubation job aid, Isolation Measures: staff had concerns about PPE changes prior to generating aerosol, Equipment: adjust equipment needs to avoid delays, and change PPE, and Communication/Personnel: minimizing staff during resuscitations. Question 2. Staff evaluations (strongly agree, (SA) to strongly disagree, (SD)): Worth the time it took: 86% SA, 14% some what agreed (SWA). An acceptable way to improve: 92 % SA, 8% SWA. An effective way to test: 92% SA, 8% SWA. Debriefing allowed staff to share ideas: 86% SA SWA 8%, and Average 6%.
  
  Conclusion(s): This study showed that SbCST methods are adaptable for preparedness evaluation and training. Participant evaluations reveal a high regard for this method for practicing/improving the COVID-19 process. This work highlights a new application of SbCSTs that could increase system preparedness and reduce errors.

  Presented at the 2021 PAS Virtual Conference

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  Simulation Based Clinical Systems Testing of a Pediatric ED to Improve Staff and Process Readiness for Pediatric Hypoglycemia

  Kevin Meilak MD and Christopher S. Kennedy

  Background: Hypoglycemia is the most common metabolic disorder in children in pediatric emergency department (ED) settings 1. Children may present with nonspecific symptoms, or asymptomatically2. So identification/treatment is very challenging. Delayed recognition and under treatment can lead to poor patient outcomes including seizure, coma, and death. Simulation-based clinical systems tests (SbCSTs) are useful to detect gaps/latent safety threats (LSTs) in system design.3-5
  
  
  Objective: Our aim was to use SbCSTs combined with rapid cycle training to test system function for ED treatment of hypoglycemia.3-5. The research questions were in 2 frames: 1. Can SbCSTs identify gaps/LSTs and recommendations for improvement and 2. Would providers consider SbCSTs acceptable way to improve?
  
  
  Design/Methods: The study took place in a children’s hospital ED and was approved by the IRB as non-human subject research. We conducted SbCSTs with staff responding to a 5-month old with hypoglycemia and used “tipping-point”(s) in care to emulate challenges and a Gamaurd mannequin and a tablet-based “monitor”(SimMon). Short scripted debriefs reviewed guidelines, staff input, and then staff repeated the simulation. Participants used a survey to evaluate the SbCSTs. Two sim staff observed, and took notes on a standardized reporting form and included staff response, any gaps/LSTs identified.
  
  
  Results: Preliminary results: 12 SbCSTs were conducted with 22 staff, 13 (59%)(7- MDs, 4-RNs, 2-APRN) filled out anevaluation. For question 1 LST identification: Staff identified 50 LSTs. Each LST was categorized for cause as follows:14 (28%) glucose gel location/administration concern, 12 (24%) need for a better job aid, 10 (20%) were related to dextrose dosing errors, 7 (14%) POC glucose recheck timing, and 7 (14%) inappropriate treatment. For question 2: An acceptable process: (strongly disagree, SD to strongly agree, SA): Worth the time it took: 85% SA, 15% somewhat agreed (SWA). Improved staff readiness: 85 % SA, 15% SWA. An effective way to test/provide solutions: 85% SA,15% SWA. The debrief allowed staff to share ideas: 85% SA, 15% SWA.
  
  Conclusion(s): This study demonstrated that simulation-based clinical systems testing (SbCST) methods are adaptable for use in a children’s hospital ED for preparedness evaluation and training. Participant evaluations demonstrate a high regard for this method. The process detected many LSTs but further data analysis with a formal FMEA process will be performed.

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  Spanish-speaking families’ perspectives on the acceptability and impact of culture and language coaching for bilingual residents

  Ryan Northup, Francisco Martinez, and Jeffrey D. Colvin

  Background: Culture and language coaching in the CHiCoS (Clínica Hispana de Cuidados de Salud) Program provides bilingual (English-Spanish) residents with longitudinal, personalized training in health care Spanish and cultural aspects of care. This intensive 1:1 training by a culture and language coach (CLC) over three years has been shown to improve residents’ skills and family satisfaction with care. Families’ perspectives on acceptability of the presence and impact of the CLC during visits have not been formally described.
  
  
  Objective:
  
  
  Design/Methods: In this descriptive, cross-sectional pilot study, we surveyed Spanish-speaking caregivers who received care from any of 18 bilingual CHiCoS residents accompanied by a CLC in our academic pediatric primary care clinic. The 10-question survey was created by the study team in Spanish using a formal process including piloting and revision. Respondents surveyed by telephone after their visit were asked how well the resident spoke and understood Spanish, effectiveness of communication, how the CLC impacted communication, future preference for coached vs interpreted visits, and overall satisfaction.
  
  
  Results: Sixty of 67 recruited parents (90%) completed the survey. A majority reported that their resident spoke (65%) and understood (63%) Spanish very well, with little or no intervention needed from the CLC. The remainder felt that the resident spoke well but needed occasional support from the CLC to achieve complete communication. None had major difficulty understanding their resident. Overall communication was either “very easy and direct without problems” (57%) or “more or less easy,” with problems being “quickly resolved” (43%). Most felt that the CLC improved communication “a lot” (77%) or “somewhat” (10%). For a hypothetical future visit, 58% preferred a coached visit with a doctor speaking at least some Spanish to an interpreted visit with a doctor speaking no Spanish; the remainder said either option would be equally good. None preferred an interpreted visit. All respondents were either “very satisfied” (83%) or “satisfied” (17%) with the care given by the resident-CLC team.
  
  Conclusion(s): Spanish-speaking caregivers strongly support culture and language coaching for bilingual pediatric residents and described positive impact on in-visit communication. Despite the majority of CHiCoS residents not yet passing their validated language proficiency exams, all families reported complete communication and satisfaction with their visits.

  Presented at the 2021 PAS Virtual Conference

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  Teaching Pediatric Procedural Pain and Anxiety Management to Residents: Early Outcomes of a Newly Developed Curriculum

  Jennifer J. Dilts, Brian R. Lee, Shobhit Jain, Ross Newman, Sarah Fouquet, Michael Brancato, and Kadriye O. Lewis

  Background: Poorly managed pediatric pain has negative long-term outcomes, including needle phobia, increased pain and anxiety with subsequent procedures, and healthcare avoidance in adulthood. Evidence-based interventions to reduce procedural pain and anxiety are vastly underutilized, and a literature search revealed no specific curriculum to teach residents optimal skills for pain and anxiety management in minor procedures (e.g. venipuncture, laceration repair). Thus, we developed a multimedia-based lecture with PowerPoint, utilizing results from a focus group interview (conducted with 7 pediatric residents, to determine educational content and identify residents’ needs and learning preferences).
  
  
  Objective: To measure residents’ learning outcomes (knowledge, attitudes, perceived competence, and practice change) and satisfaction with a newly developed procedural pain and anxiety curriculum.
  
  
  Design/Methods: Pediatric and combined internal medicine/pediatric residents were invited to complete the curriculum online through the in-house learning management system (Cornerstone) during their emergency medicine rotation. Data were collected between July 2019 and June 2020 (pre- and post-tests, as well as a follow-up survey 3-12 months later). McNemar’s test was used to measure pre- and post-test knowledge gains while Wilcoxon signed-rank test was used to compare changes in attitudes, perceived competence, and reported changes in procedural management.
  
  
  Results: Seventy-two residents were invited to participate, with 28 completing the intervention with pre- and post-tests (39% completion rate) and 12 of those residents completing the follow-up survey. Residents increased their knowledge by 24.3% (p<0.0001) (Figure 1). There was no significant change in attitudes towards pain and anxiety management. Positive improvements, although non-significant, were seen in perceived competence and reported change in medical practice (Figures 2 and 3). Course evaluation data found that 75% of residents planned to utilize knowledge from the course in the next few weeks (Table). The majority of residents who completed the follow-up survey reported that knowledge learned in the course improved their practice and/or led to changes in their practice.
  
  Conclusion(s): Early outcomes of the curriculum revealed significant knowledge increase. Additionally, these results provide a foundation for evaluation of an online game-based version of the curriculum, which we plan to make available to learners beyond our home institution.

  Presented at the 2021 PAS Virtual Conference

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  Using Standardized Scripting to Improve Antibiotic Stewardship in a National Pediatric Urgent Care Collaborative

  Amanda Nedved, Melody Fung, Cindy Liu, Rana Hamdy, and Amanda Montalbano

  Background: A study using administrative data reported urgent care providers as having the highest rates of inappropriate antibiotic use for upper respiratory illnesses. In a national survey, pediatric urgent care providers reported family expectations as a primary driver for prescribing inappropriate antibiotics. Standardized scripting has been effective at reducing unnecessary antibiotics while increasing family satisfaction.
  
  
  Objective: To reduce inappropriate prescribing for upper respiratory infections (acute otitis media (AOM), otitis media with effusion (OME), and pharyngitis) in pediatric urgent cares by 20% by December 1, 2020 through use of standardized scripting in Year 2 of a national pediatric urgent care quality improvement collaborative.
  
  
  Design/Methods: Participants were recruited via email, newsletters, and webinars from pediatric urgent care national societies. Each site committed at least 3 providers who each submitted data from 10 encounters per month. Antibiotic prescribing was defined as appropriate based on consensus guidelines. Previously published antibiotic stewardship scripting for viral upper respiratory infections was adapted for use with the three target diagnoses. Patient and family advisors reviewed all scripting and their feedback was incorporated into the revised standardized scripting. Clinical examples for each diagnosis using the standardized scripting were provided to the collaborative by use of digital cartoon videos, written framework, and templated discharge instructions. Data from clinical encounters were submitted via a REDCap form, analyzed for inappropriateness, and reported back to participating sites via run charts during monthly webinars.
  
  
  Results: The 104 participants from 10 institutions submitted 1,150 encounters for analysis in the intervention cycles (May-December 2020). Overall inappropriate antibiotics decreased from 26.4% to 16.6% (p=0.13). Inappropriate antibiotic use decreased in AOM (38.6% to 26.5%; p=0.12) and pharyngitis (14.5% to 8.8%; p=0.26). OME increased from 30.8% to 46.7% (p=0.18) (Figure 1). During the study immediate antibiotic prescriptions for OME decreased; however, delayed prescribing increased (Figure 2).
  
  Conclusion(s): In its second year, this national collaborative developed standardized scripting to overcome the barrier of perceived family expectations to decreases inappropriate antibiotic prescriptions in pediatric urgent care for AOM and pharyngitis. Future interventions will target the inappropriate use of delayed prescribing in OME.

  Presented at the 2021 PAS Virtual Conference

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  Utilization of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage in Pediatric Patients on ECMO

  Gina Patel, Jenna Miller, Thomas M. Attard, and Asdis Finnsdottir Wagner

  Hemorrhagic and thrombotic complications on Extracorporeal Membrane Oxygenation (ECMO) support are associated with significant morbidity and mortality. There is a paucity of literature describing the incidence and management of Gastrointestinal (GI) bleeding on ECMO. We describe the use of enteral tranexamic acid (TXA) as an alternative strategy in two pediatric patients with GI hemorrhage on ECMO. Case 1 A 5-year-old with Wilms Tumor required Veno-Venous ECMO due to respiratory failure associated with pulmonary hemorrhage and air-leak syndrome. Her course was complicated by severe GI hemorrhage refractory to IV proton pump inhibitor (PPI), IV TXA and octreotide infusions. Concomitant IV TXA and cessation of systemic anticoagulation coincided with emergent transition to Veno-Arterial (VA) ECMO after cannula thrombosis. Procedural interventions included esophagogastroduodenoscopies (EGD) revealing gastric ulcers, two endovascular embolization procedures, and a third arteriogram due to continued bleeding that did not identify a source. Enteral TXA (20 mg/kg q 8 hours) was then begun with resolution of GI bleeding, reduction in blood product transfusion and no further emergency circuit changes. She survived to hospital discharge. Case 2 A 3-year-old with a burn injury required VA ECMO due to cardiopulmonary collapse. Her course was complicated by GI hemorrhage. She received a PPI, octreotide infusion and was started on IV and enteral TXA (10 mg/kg q 8 hours). An EGD did not identify a bleeding source. There was no interruption in circuit anticoagulation or integrity. She remained on enteral TXA for 48 hours until GI bleeding resolved. She survived to ECMO decannulation. Patients supported by ECMO require systemic anticoagulation thus making GI bleeding difficult to manage. We report the use of enteral TXA to provide anti-fibrinolysis. This was associated with cessation of bleeding but not associated with further circuit thrombosis. Enteral TXA can be an additional tool used for GI bleeding on ECMO.

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  Virtual Child Neurology Education During COVID-19 and Beyond

  Jennifer J. Dilts and Rose N. Gelineau-Morel

  Background: Even prior to the Coronavirus Disease 2019 (COVID-19) pandemic, Children’s Mercy Kansas City’s large neurology division struggled to engage learners in educational conferences. With 113 division members across 5 locations, attending conferences was challenging. While some conferences were live-streamed, we offered no recorded lectures, and most conferences were attended solely by trainees and 3-4 select faculty. COVID-19 eliminated in-person group learning opportunities.
  
  
  Objective: We aimed to rapidly develop and implement a comprehensive and inclusive virtual child neurology curriculum and assess its impact.
  
  
  Design/Methods: We created a neurology education “team” using Microsoft® Teams. Within 1 week of beginning social distancing, we offered an average of 4 live virtual lectures per week, increased from 2 weekly lectures prior to COVID-19. Lectures covered diverse topics (e.g. quality improvement, empathy, leadership) in addition to clinical neurology. We recorded and stored all lectures and supplementary materials in Microsoft® Teams. We distributed a survey after the third and fourth weeks of virtual education, and again after 3 months.
  
  
  Results: Survey response rate was 92% (104/113) for week 3, 84% (95/113) for week 4, and 55% (62/113) at 3 months. Percentage of learners attending at least 1 lecture per week increased from 28% (pre-COVID-19) to 74% (week 3), and this gain was sustained at 3 months (88%) (Figure 1). Attendance was well-distributed amongst all types of learners (Figure 2), averaging 22 participants per lecture (SD 9.2). Mean learner satisfaction increased from 5.7 out of 10 (pre-COVID-19, SD 2.3) to 8.5 out of 10 (3 months, SD 1.25, 2-tailed paired t-test p<0.001) (Figure 3). Learners appreciated easy access to educational materials, including viewing recorded lectures. At 3 months, 88% of respondents wished to continue virtual education, and 60% of clinical staff planned to change their work practice based on information they learned. Sixty-seven percent of trainees “agreed” or “strongly agreed” that the virtual curriculum improved how prepared they felt for upcoming examinations. Rapport across the division increased, with 85% of respondents feeling more connected to colleagues.
  
  Conclusion(s): COVID-19 was a disruptive innovation, catalyzing the rapid formation of a virtual neurology curriculum. Our curriculum increased learner satisfaction, engagement, and rapport. Nine months into the pandemic, we continue to offer several virtual neurology lectures each week.

  Presented at the 2021 PAS Virtual Conference

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  Where are they now? Spanish utilization and career direction of graduates of a pediatric bilingual continuity clinic

  Jodi Dickmeyer, Katie McAnany, Sarah Stone, and John Cowden

  Background: The Clínica Hispana de Cuidados de Salud (CHiCoS) Program was created in 2009 to prepare bilingual (English-Spanish) pediatric residents to independently give safe, effective care to Spanish-speaking families. By providing 1:1 support from a culture and language coach over three years of residency, CHiCoS has improved residents’ cultural and linguistic skills and families' perceptions of care. The effects of such training on residents’ future careers have not been formally studied.
  
  
  Objective: To describe the careers of former CHiCoS residents, the impact of culture and language training on their practice, and opportunities for post-CHiCoS cultural and language training.
  
  
  Design/Methods: In this descriptive, cross-sectional study, we created and sent a digital survey (26-44 questions depending on branching logic) to former CHiCoS residents including details of their current and previous practice, Spanish utilization with patients/families, maintenance of Spanish proficiency, impact of CHiCoS on career satisfaction, and desire for ongoing culture and language training. All CHiCoS residents graduating from 2011-2019 were included, except those who did not complete the program or who were authors of this study.
  
  
  Results: Twenty-four of 33 CHiCoS graduates (73%) completed the survey. A majority worked in academic (14/24) and urban (14/24) settings. Almost all who were qualified bilingual staff upon CHiCoS graduation (N=18) worked in settings with Spanish-speaking patients/families (94%) and used their Spanish skills in greater than half of their visits (89%). Among graduates seeing >20% Spanish speaking patients (N=9), all but one felt they maintained or improved their Spanish skills. Most of those with <20% Spanish-speaking patients (10/13) reported maintaining their proficiency level, while those with no Spanish-speaking patients (N=2) felt their skills had eroded. CHiCoS training had a moderate to large impact on career satisfaction for 83% of graduates (Table, Figure), and 71% reported a desire for further support in cultural and linguistic skill development, including post-CHiCoS culture and language coaching.
  
  Conclusion(s): Culture and language coaching for bilingual residents leads to careers serving culturally and linguistically diverse patients and families. Language skills developed in residency can be maintained through ongoing use in future practice, but most graduates would like to continue formal culture and language training, even after reaching a professional level of proficiency.

  Presented at the 2021 PAS Virtual Conference

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  Subacute thromboembolic pulmonary hypertension with acute clinical worsening but improving CT findings - a case reporrt

  Doaa Aly, Alvin Singh, Pamela Finn, Kate Carp, and Brian Birnbaum

  ackground: • Subacute massive pulmonary embolism (PE) is associated with high mortality. • The subacute presentation makes it difficult to diagnose and older clots are less amenable to systemic thrombolysis. • This can result into increased likelihood of recurrence and thromboembolic pulmonary hypertension Case description: • 17-year-old, previously healthy male presented with a month of exertional dyspnea, initially misdiagnosed with asthma. • CT demonstrated diffuse PE on repeat presentation (Fig1). • Echocardiography demonstrated moderate to severe RV dilation and systolic dysfunction and suggested an RV systolic pressure of 73mmHg + RAP. • He was subsequently admitted to the ICU and received a day of r-TPA therapy. • Repeat echocardiogram showed improved RVSP and RV function, and he was started on rivaroxaban. • 3 months later he had increased dyspnea with NYHA Class III symptoms • An echocardiogram demonstrated worsened RV function and pressure, although repeat CT suggested improved PE burden (Fig. 2). • Cardiac catheterization revealed a cardiac index of 1.75 L/min/m2 and PVR of 23 Wood Units * m2 (Fig 3). • He arrested during catheterization and was placed on ECMO. • Alteplase, angioplasty and stenting were attempted, and he was referred for pulmonary endarterectomy at another institution. • He developed acute renal and hepatic failure and ultimately succumbed to his death. Conclusion: Thromboembolic pulmonary hypertension can develop subacutely yet progress rapidly. It is often diagnosed late and has a high mortality rate; therefore, high index of clinical suspicion and prompt treatment is imperative. Disclosure: The authors of this case report have no financial disclosures. Fig 1: CT at initial presentation demonstrating widespread PE with multiple filling defects seen throughout the segmental pulmonary arteries to all lobes of both lungs Fig 2: CT 3 months later, significant obstruction of the distal pulmonary vasculature bilaterally and pruning, giving a false impression of improved clot burden Fig 3: (a) Cath angiography on the first day of readmission (3 month post initial presentation, showing significant obstruction of the right lobar arteries and severely attenuated peripheral pulmonary vasculature. (b) cath angiography on the following day showing rapid progression with almost absent peripheral vascular flow.

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  “ECMO IN A BAG”: Successful Adaptation and Implementation of a Novel Conference Idea

  Johanna I. Orrick, Debra E. Newton, Kari L. Davidson, Jenna Miller, and Alyssa Stoner

  INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) is an ever-evolving technical landscape that requires an advanced level of education. At our institution, a 367-bed pediatric teaching and research facility, learners include registered nurses, registered respiratory therapists, advanced practice registered nurses, resident physicians, pediatric and neonatal intensive care physicians. A certification class followed by an advanced course covers ECMO diagnoses, complications, equipment, and management prior to providing care for ECMO patients in our institution. Educational strategies include high and low fidelity simulations, didactic learning, and clinical hours at the bedside. A desire to increase the experiential learning opportunities was identified as an ECMO leadership goal. In 2018, a team member attended a conference and returned with a low fidelity simulation concept “ECMO in a Bag” from The Hospital for Sick Children in Toronto, Canada. This novel educational concept was subsequently adapted into a dynamic experiential teaching tool that met the interactive learning needs of the Children’s Mercy ECMO educational curriculum. METHODS: The “ECMO in a Bag” concept was first observed in May 2018 at the International Pediatric Simulation Society Workshop. The first version for our hospital was established with laminated equipment photographs and labels in September 2018 and was expanded upon in November 2018 to include non-sterile tubing to connect the photographs together schematically. The tubing, photos, and labels were intended to be used as an assessment for early ECMO learners. Introduction of “ECMO in a Bag” occurred in the August 2019 ECMO certification course. Modifications were implemented to develop an “Introductory ECMO in a Bag” after observations of the novice course participants deemed the task too difficult. In February 2020, the Advanced ECMO course utilized “ECMO in a Bag” in its original version for advanced learners. The class was divided into two teams and then competed against each other to correctly “assemble” an ECMO pump. All participants completed post surveys for each educational experience. RESULTS: When the original “ECMO in a Bag” was applied to 10 novice ECMO learners in August 2019 it was regarded as too difficult by the coordinators. The strategy was modified in the moment, using the laminated equipment names matched to an already assembled nonsterile ECMO pump along with definitions. The revised “Introductory ECMO in a Bag” has since been repeated in the ECMO certification course of 15 learners in August 2020. One hundred percent of the novice learners in both the 2019 and 2020 introductory class surveyed stated the hands-on sessions including “ECMO in a Bag” were effective and engaging. Quotes from the post class surveys included “I really enjoyed the breakout session looking at the circuit. Great to start understanding all of the circuit components,” “Hands on visualization was great, allowed for putting information together”. Additional positive feedback was gleaned from the application of the original “ECMO in a Bag” during the Advanced ECMO courses. One hundred percent of the transitional learners surveyed scored the hands-on portion of ECMO learning as beneficial. Comments included “Enjoy breaking up the talks with hands on activities,” and “I enjoy the games! It really breaks up the day.” DISCUSSION: The evolution of the experiential concept of “ECMO in a Bag” has been well received and is ongoing. It has been adapted for two different levels of ECMO learners in our hospital.. It is now used with resident physicians as well during shadowing experiences with the ECMO team. ECMO coordinators also use “ECMO in a Bag” to teach new critical care bedside nurse

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  A unique cause of elbow pain and loss of range of motion in a 13-year-old

  Thomas Munro and Brian S. Harvey

  A 13-year-old right hand dominant young lady presented to a pediatric sports medicine clinic for evaluation of decreased ROM and pain in her left elbow with an associated locking sensation that had been occurring for over a year. Two weeks prior to presentation, these symptoms had been acutely worsening as she was practicing for over 10 hours per day for an upcoming dance competition. The patient’s pain is described as a “tightness” and is localized to her antecubital fossa medial to her biceps tendon. The feeling of tightness occurs most prominently with end extension and flexion of the elbow. She has had no associated fever, chills, fatigue, weight loss, swelling, bruising, numbness, tingling, previous reported injury in her elbow, or other pain or mechanical symptoms in any other joint. On exam the patient lacked 5-10° of full extension of the elbow on the left while exhibiting 5° of hyperextension on the right. She is tender to palpation (TTP) over the proximal ulna, flexor tendon mass, capitellum, and biceps tendon as it crosses the antecubital fossa. She is not TTP over the medial epicondyle, lateral epicondyle, olecranon, distal ulna, or on any region of the radius. Initial differential remained broad and included biceps tendinopathy, osteochondritis dissecans, subluxation, dislocation, occult fracture, osteochondroma, osteoarthritis, inflammatory arthritis, and heterotrophic ossification, among other possible etiologies. Frontal, oblique and lateral views of the left elbow showed multiple small heterogeneous calcifications in the antecubital space (the largest measuring approximately 1 cm in greatest diameter). No joint effusion, fracture, or dislocation were present. Soft tissue calcifications are caused by a wide range of pathologies, which can be grouped broadly into dystrophic, iatrogenic, metabolic, connective tissue disease, metastatic, and idiopathic causes. To further elucidate these calcifications an MRI with and without contrast of the left elbow was obtained. The MRI showed a Venous Malformation (VM) with associated phleboliths located anterior to the distal humeral diaphysis, in the region of the posterior aspect of the brachialis muscle, with an associated small intraosseous component in the humerus. VMs are present at birth and grow proportionately as the child develops. They are typically cutaneous, subcutaneous, or mucosal but can be located anywhere throughout the body. VM symptom presentation is highly variable and will often become symptomatic later in life. Treatment is controversial and options include symptomatic support (compression or NSAIDS), surgery, sclerotherapy, and possibly targeted therapy with sirolimus. In this instance the patient was referred to orthopedic surgery and vascular malformation clinic for further management. This case showed Venous Malformation to be a rare cause of elbow pain with associated decreased ROM and a locking sensation in a 13-year-old female patient.

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  Development and Interim Analysis of a Cystic Fibrosis-Specific Antibiogram

  Claire Elson, Ellen Meier, Douglas Swanson, Rangaraj Selvarangan, Megan Gripka, and Christopher M. Oermann

  Antimicrobial therapy is essential to treat cystic fibrosis (CF) lung infections. Empiric antimicrobial selection is generally based on previous culture information and, if available, an institution-specific antibiogram (ABGM). Most institutions antibiograms exclude cultures from individuals with cystic fibrosis, imposing challenges with empiric antimicrobial selection and monitoring susceptibility patterns over time. A cystic fibrosis-specific antibiogram may help drive population-specific antimicrobial selection and improve antimicrobial stewardship.

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  Development of Drive-Through and Mail-In Systems for Obtaining Surveillance Respiratory Specimens in a Pediatric Cystic Fibrosis Center

  Ellen Meier, Paula Capel, and Christopher M. Oermann

  Routine surveillance cultures are an essential part of health maintenance for people with cystic fibrosis (CF). The Cystic Fibrosis Foundations (CFF) recommends that respiratory cultures be obtained every three months. The CF Care Center at Children’s Mercy Kansas City (CMKC) also obtains respiratory cultures when there is an acute change in respiratory symptoms. The COVID-29 pandemic resulted in ambulatory clinic closures and an inability to obtain surveillance respiratory cultures. A creative solution for obtaining respiratory cultures was needed during the pandemic.

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  Incidental Diagnosis of Dual Arterial Supply of the Right Lower Lobe

  Christopher Mathis, Jay Crockett, and Maria Kiaffas

  Description of Clinical Presentation: A 15 year old male with a 2 week history of fever and abdominal pain had an abdominal/pelvic MRI demonstrating osteomyelitis of his right hip. Incidentally an anomalous vessel arising from the abdominal aorta and coursing to the vasculature of the lower right lung lobe was identified and he was referred to cardiology for further evaluation. He is an athlete with no history of cardiac or respiratory symptoms and his cardiac physical examination was within normal limits. Diagnostic Techniques and Their Most Important Findings: An echocardiogram was initially obtained; imaging was difficult due to suboptimal acoustic windows and revealed normal intracardiac anatomy and normal ventricular size and systolic function. Detailed profile of the right pulmonary venous connections was not feasible and an abnormal flow close to the inferior vena directed towards the thoracic cavity was seen. The suspicion of an anomaly involving the right lung vasculature was raised and a cardiac MRI (CMRI) was obtained in order to better assess cardiovascular anatomy and calculate Qp:Qs. CMRI revealed an anomalous systemic arterial supply of a small portion of the right lower lobe without pulmonary sequestration. The artery originated from the celiac trunk with proximal narrowing of the vessel close to its origin and post-stenotic dilation. There was normal right pulmonary artery arborization and supply to this segment, indicating dual arterial supply. Qp:Qs was normal (1.03) with normal atrial and ventricular volumes indicating minimal extracardiac shunt. Learning Points from this Case: Incidental MR imaging findings are not uncommon and further imaging work-up as well as management should be individualized. In this case a systemic arterial supply to the right lower lung was inadvertently identified and further imaging revealed no hemodynamic burden associated with it. Various case reports address similar incidental discoveries, usually associated with work-up for hemoptysis, congenital heart disease and often associated with lung sequestration. Ligation or embolization of the systemic feeding vessel to the lung due to risk of hemoptysis is often undertaken. In the case of our patient, the morphology of the feeding vessel in combination with normal lung appearance, normal Qp:Qs, and lack of symptoms led to a consensus to not intervene but to observe with regular follow-up.

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  An Unexpected Global Health Experience in Manila

  Susan McAnany

  Describes her experience in the NICU of the Fabella Memorial Hospital in Manila, Philippines.

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  Baylor International Pediatric AIDS Initiative (BIPAI): Maseru, Lesotho

  Whitney J. Cameron

  Describes her experience working in Maseru, Lesotho.

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  FIT Clinical Decision-Making: Brain abscess in a nonfenestrated Fontan patient

  Bethany Runkel, Natalie Shwaish, Geetha Raghuveer, and William Drake

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  FIT Clinical Decision-Making: Isolated polymorphic ventricular tachycardia in a pediatric patient: an unusual presentation of acute mycocarditis

  Natalie S. Shwaish, Bethany Runkel, and Lindsey Malloy-Walton

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  FIT Clinical Decision-Making: Uhl's anomaly: an uncommon cause of fetal cardiomegaly

  Bethany Runkel, Atif Ahmed, Tara Swanson, and Maria Kiaffas

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  FIT Clinical Decision-Making Unusual echocardiographic findings of myocarditis mimicking an aortic runoff lesion

  Sarah Studyvin, Christine Symes, Barbara A. Pahud, and Nitin Madan

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  Global Health Elective in Santiago Atitlan, Guatemala

  Sarah Greenberg

  Describes her experience working in Hospitalito Atitlan in Santiago Atitlan, Guatemala.