Posters

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.

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Global Health Elective: Santo Domingo, Dominican Republic

Joan Strong

Describes the experiences of a pediatric anesthesiology fellow's time working Medical Aid for Children of Latin America (MACLA) in Santo Domingo, Dominican Republic.
Global Health Elective: Trujillo, Peru

Naseem Nikaeen

Describes pediatric resident's learning experiences to provide better medical care in low resource environments.
Global Health Experience in Botswana

Sarah Bieser

Describes experience providing care at the Botswana-Baylor Children's Center of Excellence in Gabarone, Botswana and the Princess Marina Hospital.
Global Health Experience in Botswana

Jared Willard

Describes a global health learning experience at the Botswana Baylor Center of Excellence with emphasis on treating pediatric HIV/AIDS patients.
Global Health Experience in the Philippines

Nina Zanaboni

Describes experiences working in the Dr. Joe Fabella Memorial Hospital NICU and Philippine Children's Medical Center ER.
Global Health Experience: Laos Friends Hospital for Children

Ashley Daniel

Outlines the learning experiences of a pediatric resident working within the Laos Friends Hospital for Children.
Global Health Rotation Caring for Children with Medical Complexity in Russia

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.
Implementing the Summer Food Service Program within the Healthcare Setting

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.
Panama: Exploration of Multiple Health Care Settings and Spanish Immersion

Danielle Gonzales

Details how the urban and rural settings of Panama offer an unique opportunity for Spanish immersion and disease pathology learning experiences.
Pediatria en Panama: A Spanish International Health Experience

Vickie Blanco

Reports learning experiences while working with several pediatric care facilities in Panama.
Philippine Children's Medical Center and Dr. Jose Fabella Memorial Hospital

Adam Grumke

Describes medical learning experiences of pediatric resident while working in two Philippine medical facilities.
Sawubona from Swaziland! A Global Health View of the HIV/AIDS Epidemic in Swaziland

Abby Hardin

Describes a global health learning experience with Baylor International Pediatric AIDS Initiative in Swaziland.
"Sterile Cockpit": How Utilizing Aviation Regulations Can Reduce Errors in ECMO Procedures

Sarah P. Jimenez, Johanna I. Orrick, Kari L. Davidson, and Debra E. Newton

The "Sterile Cockpit Rule," developed in 1981 as an aviation regulation, was adapted by the ECMO core team to promote a distraction-free environment during critical ECMO procedures. Upon review of the data including tracking of interruptions, errors, and staff experience, it is evident that the concept of Sterile Cockpit has streamlined procedure efficiency, as well as safety.
Swaziland Global Health Elective

Danielle Horton

Describes a global health learning experience
The Lake Clinic Cambodia, A MedPeds Experience . . .

Jeremy Jennings and Jennifer Watts

Describes global health learning experience providing ambulatory care in Cambodia.
Utility of Point-of-Care Beta-hydroxybutyrate Testing for Predicting Diabetic Ketoacidosis in the Pediatric Emergency Department

Michelle Knoll, Kelsee Halpin, and Ryan McDonough

The objective of our investigation was to describe the diagnostic characteristics of point-of-care capillary beta-hydroxybutyrate (BOHB) testing to predict diabetic ketoacidosis among pediatric patients presenting with hyperglycemia in the pediatric emergency department.
Save the Pharmacy Piggy Bank: Managing Mega High-Cost Drugs

Richard K. Ogden Jr., Jerame Hill, and Sam Abdelghany
Early Identification of Depression in Patients with Pediatric Epilepsy

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.
Developmental Intervention Patters in a Level IV Neonatal Intensive Care Unit (NICU)

Grace Winningham, Cy Nadler, Sarah Nyp, Eugenia K. Pallotto, and Ashley Sherman

Background: There are no evidence-based standards for if/when developmental interventions should be initiated while an infant is in the neonatal intensive care unit (NICU), or these services yield incremental benefit. To support future prospective studies evaluating the neurodevelopmental benefits of NICU-based services as well as standardizing protocols for developmental interventions in the NICU, a thorough descriptive investigation of current developmental intervention practices is necessary. Objective: To describe trends in the delivery of developmental interventions [physical therapy (PT), occupational therapy (OT), speech-language therapy (ST), child life (CL), and music therapy (MT)] in high-risk infants in a large level-IV NICU. Methods: Electronic records of infants discharged over a 30 month period were manually reviewed to extract demographic variables and therapy patterns. Results: Records for 449 extreme and very preterm infants (23 0/7 to 31 6/7 weeks gestation) were reviewed. Birth weights ranged from 0.340 kg to 2.570 kg. Overall, ST had the lowest rate (6.7%) and child life had the highest rate (73.3%); ST was started at the oldest postmenstrual age at 53 0/7 ± 8.4 weeks. Eight percent of the infants had a tracheostomy, 18.0% had a gastrostomy-tube. Infants with a tracheostomy or gastrostomy-tube were more likely to receive all of the interventions (p < 0.05). The tracheostomy infants receiving ST had a higher birth weight and a longer hospital stay (p’s < 0.05), irrespective of gestational age. For each developmental intervention, infants receiving the therapy had a longer hospital stay (p < 0.0001). There were no significant differences in use of any of the therapy types related to gender, race, or language. Conclusions: This study reveals varying rates of developmental interventions in < 32 week gestation infants, with longer hospital stays associated with higher rates of interventions. ST was the least utilized modality and initiated on average at the oldest postmenstrual age, possibly reflecting low provider familiarity with potential ST benefits. More trends on NICU-based services is needed to support prospective studies investigating the benefits.
Integration of a Pharmacist in a Pediatric Medical Home for Children with Medical Complexity

Alannah K. Yoder, Richard K. Ogden Jr., Ingrid A. Larson, and Emily J. Goodwin

Background/Objectives

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.

Description

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.

Significance

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.
Oxcarbazepine Overdose in a Polysubstance Related Suicide

Melissa Beals, Robert J. Krumsick, C. Clinton Frazee III, Lindsey J. Haldiman, and Uttam Garg

Introduction
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.

Objective
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.

Case History
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.

Methods
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).

Conclusion
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,
Developmental intervention patterns in a level IV neonatal intensive care unit (NICU)

Grace Winningham, Cy Nadler, Sarah Nyp, Eugenia K. Pallotto, and Ashley Sherman

Background: There are no evidence-based standards for if/when developmental interventions should be initiated while an infant is in the neonatal intensive care unit (NICU), or these services yield incremental benefit. To support future prospective studies evaluating the neurodevelopmental benefits of NICU-based services as well as standardizing protocols for developmental interventions in the NICU, a thorough descriptive investigation of current developmental intervention practices is necessary. Objective: To describe trends in the delivery of developmental interventions [physical therapy (PT), occupational therapy (OT), speech-language therapy (ST), child life (CL), and music therapy (MT)] in high-risk infants in a large level-IV NICU. Methods: Electronic records of infants discharged over a 30 month period were manually reviewed to extract demographic variables and therapy patterns. Results: Records for 449 extreme and very preterm infants (23 0/7 to 31 6/7 weeks gestation) were reviewed. Birth weights ranged from 0.340 kg to 2.570 kg. Overall, ST had the lowest rate (6.7%) and child life had the highest rate (73.3%); ST was started at the oldest postmenstrual age at 53 0/7 ± 8.4 weeks. Eight percent of the infants had a tracheostomy, 18.0% had a gastrostomy-tube. Infants with a tracheostomy or gastrostomy-tube were more likely to receive all of the interventions (p < 0.05). The tracheostomy infants receiving ST had a higher birth weight and a longer hospital stay (p’s < 0.05), irrespective of gestational age. For each developmental intervention, infants receiving the therapy had a longer hospital stay (p < 0.0001). There were no significant differences in use of any of the therapy types related to gender, race, or language. Conclusions: This study reveals varying rates of developmental interventions in < 32 week gestation infants, with longer hospital stays associated with higher rates of interventions. ST was the least utilized modality and initiated on average at the oldest postmenstrual age, possibly reflecting low provider familiarity with potential ST benefits. More trends on NICU-based services is needed to support prospective studies investigating the benefits.
Social Work Triage in a School District for the School Year 2017-2018

Libby Milkovich, Briana A. Woods-Jaeger, and Allison Zoromski PhD

Purpose: One in 7 children ages 2-8 have a behavioral, mental or developmental diagnosis. The prevalence of mental health disorders increases in adolescence to over 20%. Only 36% of youth who have a mental health disorder in their lifetime receive treatment. School-based services can address barriers to care. The purpose of this study was to determine the frequency and indication of referrals for students to 19 hospital-employed clinical social workers placed within a school district during one academic year (2017- 2018) and how the indication varies with level of schooling.

Methods: Students were referred to social workers by self, classmates or school personnel. The student’s school name, age, indication for assessment and place of referral were collected. The entries were analyzed if a school was listed with the entry. District demographics were collected from publicly accessible sources. Descriptive analysis was performed.

Results: For the 2017-2018 school year, enrollment for K-12 students was over 20,000. Race of the students were primarily Caucasian (74%). All schools had less than 10% receiving free/reduced lunches. Indications for triage totaled 1643, 43% from high school (HS), 26% from middle school (MS), 30% from elementary school (ES). Behavioral problems were most frequent (23%), followed by anxiety (22%). Average age for behavioral problems was 10.6(SD 3.5); with 16% HS, 27% MS, and 69% ES. Average age for anxiety was 13.3(SD 3.3); with 41% HS, 27% MS, and 32% ES. Suicide ideation/attempt had a frequency of 10% with an average age of 14.5(SD 3.0); with 62% HS, 13% MS, and 26% ES. Depression had a frequency of 5% with an average age of 14.0(SD 2.656) and 46% HS, 33% MS, and 21% ES. ADHD had a frequency of 3% with 28% HS, 17% MS, and 55% ES.

Conclusions: Internalizing disorders were the most frequent indications. The indications varied by level of schooling. School mental health professionals like social workers are able to provide triage and community mental health referrals to some. An innovative approach is needed within the schools. Currently, we are conducting a multimodal (survey, focus group, interviews) needs assessment within the school district to inform an innovative approach.
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.