Research at Children's Mercy Month 2025

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  Addressing Microaggressions and Racism Through Simulation-Based Training

  Tyandra Moore, Leah Jones, Lisa Ell, Robert Schremmer, Alyssa Stoner, Christopher Thomas, and Frances Turcotte Benedict

  Purpose: Healthcare disparities constitute a critical challenge in contemporary medicine, with robust evidence demonstrating marked differences in health outcomes based on race, ethnicity, and socioeconomic status. This training program empowers healthcare providers to recognize and respond to discrimination, microaggressions, and racism in clinical environments, demonstrating simulation’s effectiveness as a medical education tool for addressing these challenges in the medical workplace.

  Method: The program utilizes a simulation-based training approach featuring three scenarios designed to equip trainees with skills to take action in instances of microaggressions and racism in medicine: (1) Mistaken Identity - confronting microaggressions experienced by an underrepresented in medicine trainee; (2) Cultural Bias in Patient Care - examining bias against foreign-trained physicians; and (3) Systemic Racism in Clinical Care - analyzing disparities in pain management for pediatric patients with sickle cell disease. Each simulation follows a structured methodology including pre-briefing, 15–20-minute scenario with standardized participants, structured debriefing, and facilitated skill-building using evidenced-based response tools. Seventy –three pediatric residents participated in the simulations. Trainee feedback was obtained on the simulation objectives using a 5-point Likert scale.

  Results: The participant evaluation of the simulation objectives was overwhelmingly positive. The feedback response rate was 91.7% (67/73). No one gave a poor or very poor rating. Ninety-six percent of respondents agreed the knowledge and experience they gained from this session will improve their practice. In addition, 71.6% strongly agreed the simulations acknowledged the impact of racism and power dynamics in patient care, 64.2% strongly agreed they can identify race-based microaggressions, and 61.2% strongly agreed they can acknowledge microaggressions and support recipients of microaggressions.

  Conclusions: Simulation is a valuable medical education tool to develop skills in navigating microaggressions, racism and health equity in the medical workplace. This simulation-based training program improves trainees’ self-reported ability to identify and acknowledge microaggressions and racism in the medical workplace as well as support recipients of microaggressions and racism. This simulation-based training enhanced healthcare providers' capacity to engage in critical dialogue, recognize and mitigate bias while supporting affected individuals and uphold professional standards.

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  Anterior nasal swabs compared to nasopharyngeal swabs for detection of respiratory viruses in children

  Abby Kietzman, Nicole Neeley, Rangaraj Selvarangan, Dithi Banerjee, Jennifer Goldman, and Jennifer Schuster

  Background: Respiratory viral testing often uses invasive nasopharyngeal (NP) swabs, which can be painful and require trained personnel. Anterior nasal swabs (NS) are less invasive and can be self-collected. The sensitivity of NS compared to NP specimens for detecting multiple respiratory viruses in children are not well described.

  Methods: Hospitalized children in Kansas City, MO, from January 2023 to February 2024, who had NP specimens obtained for standard of care multiplex respiratory viral testing in the previous 72 hours, were enrolled. NS specimens were collected and tested alongside salvaged NP specimens for adenovirus, seasonal coronaviruses, human metapneumovirus, respiratory syncytial virus, influenza, rhinovirus/enterovirus, SARS-CoV-2, and parainfluenza viruses using multiplex molecular testing. Concordance and sensitivity of NS compared to NP specimens were assessed.

  Results: A total of 147 paired NP/NS specimens were analyzed. Overall, 114 (77.6%) NP/NS pairs were concordant, including 86 (58.5%) virus-positive and 28 (19.1%) virus-negative pairs. NS sensitivity was 84.3% compared to NP, increasing to 95.7% when collected within 24 hours of NP specimens. Sensitivity for seasonal coronavirus was poor (36.4%), but was over 75% for other viruses, and 100% for adenovirus, influenza, parainfluenza, RSV, and SARS-CoV-2 within 24 hours of NP specimens. Virus cycle threshold counts were similar among paired specimens.

  Conclusions: NS specimens showed good concordance with NP specimens and high sensitivity for most viruses, except seasonal coronavirus. NS testing may enable respiratory virus monitoring outside medical settings.

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  A study on the self-reported experience of acute urinary catheterization in children and adolescents

  Lora Bear, Chris K. Fan, Heather S. Jung, Margret Kamel, and Sandeep Riar

  Background: Urinary catheterization, a common pediatric procedure, requires the use of topical anesthesia but some studies suggest no benefit of lidocaine gel over non-anesthetic gel. It is challenging to counsel patients about this procedure as the experience of catheterization in the literature is based on observation in pre-verbal and nonverbal children rather than self-report.

  Design/Methods: We included 8- to 21-year-old subjects undergoing urinary catheterization in the Emergency room or inpatient setting and used a written survey to record their experience. The survey included questions with a 5-point Likert scale. Procedural pain was measured using the Numerical Rating Scale (NRS-11), where 0 is no pain or hurt and 10 is the most or worst pain. Pain scores of 1-3, 4-6 and 7-10 were classified as mild, moderate, and severe pain, respectively. We excluded patients with developmental delay, altered sensorium, bladder surgery, chronic intermittent catheterization, neurogenic bladder, and non-English speaking subjects.

  Results: We recruited 44 patients in the study with a mean age of 14.9 years (SD 2.7), with slightly more females (54.5%) than males (45.5%). Ethnicity distribution included Caucasian (56.8%), African American (18.2%), Hispanic (11.4%), Asian (4.6%) and Other (9.1%). Most subjects underwent straight catheterization (72.7%) while the rest had an indwelling urinary catheter (27.3%). Urinary catheterization was done mostly for retention (50.0%), followed by diagnostic indication to help with ultrasound (40.9%) or urinalysis (6.8%) and acute kidney injury (4.5%). Interestingly most subjects reported anxiety but not embarrassment with the procedure (Fig 1). Only 19 subjects (43.2%) reported the use of numbing gel with catheterization and most felt that it helped them. With catheter placement, moderate or severe pain was reported by 75% (Figure 2). With catheter removal, moderate or severe pain was reported by 60.9% (Figure 2). The duration of pain with placement or removal was less than 2 minutes in over half the subjects. Finally, most subjects reported greater pain with catheterization than with a blood test or intravenous catheter placement (Figure 3).

  Conclusion: Pediatric patients report significant pain with urinary catheterization although it is brief. Most subjects reported lack of use of numbing gel which may be from lack of awareness or lack of use. Subjects who reported use of numbing gel found it helpful. Our study findings will help providers counsel patients on what to expect with urinary catheterization.

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  Bayesian Hierarchical Modeling that Leverages the Relationships Between Immune Cell Populations Measured from Spatial Proteomic Imaging Technologies

  Chase J. Sakitis, Alex Soupir, Mary K. Townsend, Courtney E. Johnson, Andrew B. Lawson, Joellen M. Schildkraut, Shelley S. Tworoger, Kathryn L. Terry, Lauren C. Peres, and Brooke Fridley PhD

  Advancements in spatial proteomic imaging techniques have improved the ability to examine the tumor immune microenvironment (TIME) and determine its impact on clinical outcomes. Multiplex immunofluorescence (mIF) imaging is one such technique that can assess multiple markers simultaneously to differentiate the separate immune cell populations in the TIME. With the progress of immunotherapy (IO) treatments, analyzing these immune profiles has become increasingly important to determine tumors that may or may not respond to IO treatments. Despite the technological development, natural challenges arise when analyzing this data including the fact that the immune cell counts are over-dispersed and studies often have repeated measurements from the same tumor sample (i.e., cores on a tissue microarray, regions of interest). From a preliminary assessment of eight standard count-based distributions to model the spatial protein data, the beta-binomial distribution was the most interpretable, top fitting, model. Using a beta-binomial framework, we have developed a novel Bayesian hierarchical model to model multiple all immune cell populations of interest simultaneously. The Bayesian hierarchical model accounts for the relationships between the different cell populations in the TIME which is otherwise ignored from the standard univariate models. By incorporating different dependency (or relationship) structures between the different immune cell populations, there is improved precision in estimation due to “borrowing of information” across the multiple markers. Our Bayesian model and its different relationship structures for modeling the relationship between immune cell populations have been applied to spatial proteomic data from three large ovarian cancer epidemiologic cohorts (N = 486) to assess the ability of the novel model to detect factors associated with immune cell inflation into the TIME

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  Burnout Prediction in Pediatric Urgent Care Providers Using Wearable Data: A Pilot Study

  George E. Quaye, Addison Leabo, J Steven Leeder, Brooke L. Fridley, and Tiffany Addington

  Burnout is a critical issue among healthcare providers, especially in high-stress environments such as pediatric urgent care (PUC). Existing tools, like the Maslach Burnout Inventory (MBI), tend to identify burnout after it has occurred. This study aims to leverage wearable technology to predict burnout before its onset, using biometric data to facilitate timely interventions. This observational study will explore the application of several machine learning (ML) models to biometric data collected from Garmin Venu 3 smartwatches, with the goal of determining the best predictive approach for burnout. Up to 50 medical providers from three PUC sites will wear Garmin Venu 3 devices for six months, with biometric features (e.g., heart rate, sleep patterns, stress, and activity levels) synced via the Garmin Health API. Participants will also complete the Maslach Burnout Inventory (MBI) surveys at baseline, 6 weeks, 3 months, and 6 months. Multivariate (multi-level) functional data analysis will assess the predictive capacity of features such as heart rate, sleep, stress, and activity. Various ML models, including linear and non-linear approaches (e.g., Random Forest, Support Vector, XGBoost, Linear Discriminant Analysis), will be compared to identify the optimal model for predicting burnout. Model performance will be evaluated using cross-validation, and predictive power will be assessed using area under the curve (AUC) and F1 score. Additionally, a Shiny application will be developed for real-time data visualization and result exploration. The findings from this study will contribute to the developmen

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  Mass Spectrometry-Based Proteomic Analysis Of Changes In Surface Expression Of Oatp1b1 And Oatp1b3 Upon Inhibition Of Palmitoylation During Co-Expression Studies

  Priscilla Flores-Ascencio, Cecilia Villanueva, Bruno Hagenbuch, and Whitney M. Nolte

  Two out of every five US adults and one out of every five US children meet the criteria for obesity. Obese patients are at an increased risk for nonalcoholic fatty liver disease (NAFLD), which can progress to nonalcoholic steatohepatitis (NASH) and cirrhosis. Compared to healthy controls, NAFLD and NASH patients have higher levels of free cholesterol and palmitoylated proteins in their liver, as well as significantly elevated plasma bile acids. Investigation of the effect of dyslipidemia associated with these disease states and how bile acid and drug transport are affected by protein-lipid modification is essential. Several uptake transporters in human hepatocytes, including NTCP, OATP1B3, OATP1B1, and OCT1, co-localize and interact. We hypothesize that these proteins are palmitoylated and localized within lipid rafts. Preliminary data demonstrate that inhibiting palmitoylation affects the function and expression of NTCP, OATP1B3, OATP1B1, and OCT1. Here, we describe the use of mass spectrometry-based proteomics to assess palmitoylation and surface localization of these transporters. We have previously shown the inhibition of palmitoylation reduces OATP1B1-mediated uptake of estradiol-17β-glucuronide. Acyl-RAC assays indicate that palmitoylation occurs at Cys24, for both OATP1B1 and OATP1B3. Proteomics analysis confirmed palmitoylation of Cys24 and identified palmitoylation at Lys19/20 in OATP1B1, N-acylation typically being undetectable using Acyl-RAC assays. Surface expression of OATP1B1 and OATP1B3 was assessed via surface biotinylation followed by targeted mass spectrometry. This method showed good linear quantification and low coefficients of variation. Preliminary LCMS results show mutating the Cys24 palmitoylation site for OATP1B1 and OATP1B3 slightly increased surface expression compared to the wild-type in coexpression studies. Surface expression of these proteins decreased only when OATP1B1 and OATP1B3 both had mutations at their Cys24 palmitoylation site. Additionally, these results informed the optimization of the surface biotinylation procedure which will enable expansion of these surface expression studies. Our data indicates that OATP1B1 is palmitoylated and that this palmitoylation alters transporter function with little effect on surface expression. We plan to expand this work to include effects on protein-protein interactions as well as other transporters. These studies are expected to expand our understanding of the post-translational regulation of hepatic drug transporters and potentially guide dosing strategies for relevant drugs in obese patients

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  Respiratory syncytial virus and metapneumovirus infect human induced excitatory neurons and trigger an innate immune response

  Gage Greening, Rebecca McLennan, Eric S. Geanes, Santosh Khanal, David Moore, Heather Mwitani, Daniel A. Louiselle, and Todd Bradley

  Certain respiratory viruses exhibit neurotropism, allowing them to invade the central nervous system and induce neuroinflammation. Neurotropic respiratory viruses can lead to a variety of symptoms including encephalitis, seizures, and acute flaccid paralysis, among others. Recent research also suggests that even in non-severe cases, long-term neurological sequelae can persist. Despite the known association of these neurotropic respiratory viruses with short- and long-term neurological manifestations, there are significant knowledge gaps regarding the basic mechanisms of neuropathogenesis that, if addressed, could provide a foundation for the development of prevention and treatment interventions. The goal of this study was to establish in vitro models of infection of the central nervous system by neurotropic respiratory viruses. We developed methods to culture both human excitatory neurons as well as a more complex brain organoid consisting of neuronal and non-neuronal cell types, including astrocytes and microglia. Our work revealed that human excitatory neurons could be infected by several neurotropic respiratory viruses including respiratory syncytial virus (RSV) and human metapneumovirus (hMPV). Furthermore, neurons exhibited distinct innate immune responses to each of these viruses. In addition, through both confocal microscopy and single-cell RNA sequencing, we showed that RSV could infect both neuronal and non-neuronal cells in brain organoids. Single cell RNA sequencing data also revealed that there was an enrichment towards infecting neuronal cells. Overall, these in vitro platforms can facilitate research into virus-host interactions for known and emerging neurotropic viruses. These findings will enable us to continue exploring mechanisms of viral entry to investigate potential therapeutics.

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  Single-Cell Analysis of Nasal Mucosa Reveals Immune Response in Respiratory Syncytial Virus (RSV) Infection

  Santosh Khanal, Eric S. Geanes, Carl F. Schreck, Daniel A. Louiselle, Alyse Peters, Nick Nolte, Libby Corkran, Anjana Sasidharan, Bradley Belden, Gage Greening, Rebecca McLennan, Tomi Pastinen, Rangaraj Selvarangan, Todd Bradley, and Elin Grundberg

  Respiratory Syncytial Virus (RSV) is a common respiratory pathogen that can cause breathing problems in babies and young kids, sometimes leading to serious health issues. Insight into pathologic immune responses and cellular dysregulations that contribute to disease severity has largely relied on invasive sampling typically restricted to critically ill and mechanically ventilated children. However, the nasal mucosa is a critical site for viral entry, making it an ideal target for studying viral pathogenesis and allows sample collection noninvasively. Here, we present an approach for simultaneous single-cell profiling and viral typing using salvaged nasal swabs obtained in pediatric clinics. First, we developed a comprehensive viral and human reference genome panel applied to 80,970 nasal cells, and mapped not only RSV, but also influenza A and B and SARS-CoV-2, infected and non-infected epithelial and immune cells. Compared to other viruses, we identified macrophages and neutrophils as the primary cellular target of RSV in the nasal mucosa and characterized a significant increase in IL-8 expressing neutrophils during infection. This was accompanied by a significant decline in ciliated cells in RSV samples compared to controls. Consistent with these findings, pathway analysis revealed significant activation of immune-related, particularly TNFα signaling via NFκB and interferon gamma response, and complement cascade pathways in both cell types, while metabolic processes like glycolysis and protein secretion showed less significant changes.

  In conclusion, our study provides insights into proinflammatory roles of macrophages and neutrophils in the nasal mucosa after RSV infection. These findings underscore the utility of single-cell genomics in unraveling complex host-pathogen interactions, highlighting potential for personalized medicine in pediatric respiratory diseases. Follow up experiments focusing on confirming our single cell sequencing findings using histological approaches and protein analyses are currently ongoing.

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  The impact of elexacaftor/tezacaftor/ivacaftor on perceived quality of life in people with cystic fibrosis aged 2-5 years

  Ashley Severin, Ellen Meier, Christopher M. Oermann, and Stephanie Duehlmeyer

  Elexacaftor/tezacaftor/ivacaftor (ETI) is a highly effective CFTR modulator therapy for people with cystic fibrosis (pwCF). It was originally approved in October 2019 for pwCF aged 12 years and older with one copy of the F508del CFTR mutation. Since that time, its FDA labeling has been expanded, with an indication down to age 2 years. It has been shown through clinical trials that ETI is associated with physical health improvements. The CF community and care teams have observed similar findings. To our knowledge, there are limited data regarding ETI and health-related quality of life (HRQOL) in the pre-school age group. The primary goal of this study is to assess the impact of ETI on parents’ perceptions of HRQOL among children 2-5 years of age with CF.

  METHODS:

  The Pediatric Quality of Life Inventory Measurement Model (PedsQL) measures HRQOL in children with chronic health conditions. The PedsQL is a validated screening tool that assesses functioning in four domains: physical, emotional, social, and daycare/school. The PedsQL parent reports for young children (ages 5-7) and toddlers (ages 2-4) were used. A 5-point response scale is used (0 = never a problem through 4 = almost always a problem). Items are reverse scored to a 0–100 scale (0 = 100, 1 =75, 2 = 50, 3 = 25, 4 = 0), so that higher scores indicate better HRQOL.

  The parents of children with CF (PoCwCF) aged 2-5 years receiving care at Children’s Mercy Kansas City CF Center and treated with ETI were contacted by EMR to enroll. Once consented, a baseline PedsQL was sent through the hospital’s Research Electronic Data Capture (REDCap) database prior to initiation of ETI. Subsequent PedsQL questionnaires were sent at 3 months and 6 months post-initiation of ETI. Data collection is ongoing with the last 12-month PedsQL being captured summer 2024.

  RESULTS:

  Twenty-eight PoCwCF were contacted for participation. Ten (36%) parents completed the baseline questionnaire. Data from 6 PoCwCF (60%) were included in the final analysis. The average age of pwCF was 3.8 years (± 0.75), most were male (4, 67%), pancreatic insufficient (4, 67%) and homozygous for F508del (4, 67%). All pwCF were previously treated with ivacaftor or lumacaftor/ivacaftor.

  The results of the mean PedsQL scores for the four domains are presented in Figure 1.

  CONCLUSIONS:

  The number of pwCF treated with ETI has steadily increased since initial FDA approval. As demonstrated in clinical trials, HRQOL increased in older age groups. These results suggest ETI use is associated with parental perception of diminished or unchanged HRQOL in the physical, social, and daycare/school domains among children age 2-5 years. The decrease in school functioning could be explained by respiratory viral season when the PedsQL was completed, which correlates with trends of increased illnesses in winter months. This may have also resulted in a decrease in the physical domain. The decrease in social functioning may be explained by increased behavioral adverse effects of ETI reported through the CF community. The only domain with increased HRQOL was emotional functioning. Despite the increase, it is noteworthy that feelings of sadness and anger were unchanged but feelings of being afraid/scared decreased post-initiation of ETI. Completion of the 12-month data assessment will be crucial in assessing overall trends. Additional data gathering will be vital in assessing the association of ETI and HRQOL in the 2-5 age group.

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  Transcriptional dynamics of natural killer cells under hyperthermic and acidic inflammatory conditions

  Heather Mwitani, Gage Greening, Rebecca McLennan, Eric S. Geanes, Santosh Khanal, and Todd Bradley

  The cellular microenvironment is maintained by various homeostatic mechanisms, such as pH and temperature regulation. These factors can alter signaling and transcriptional activity in natural killer (NK) cells, significantly impacting their activation and function. These homeostatic mechanisms can be disrupted by factors such as infection or injury, such as within the tumor microenvironment. NK cells are essential for regulating the immune response by promoting and resolving inflammation to maintain tissue homeostasis. However, the mechanisms by which NK cells sense and respond to environmental factors, such as low pH or high heat, are not fully understood. In this study, we investigated the impact of inflammatory conditions (acid and heat) on human NK cells purified from the blood of healthy donors. NK cells were cultured in low pH (pH=6.5) and high temperature (40°C) environments. After 4 hours of culture, RNA was isolated from NK cells and underwent RNA sequencing and supernatant was harvested for cytokine analysis. We found that NK cells undergo specific gene alterations in response to inflammatory environments. These alterations influence the secretion of various cytokines and chemokines including GM-CSF, IFN-γ, Granzyme A, Granzyme B, MIP1-α, and sFasL. These findings indicate that NK cells utilize specific transcriptional regulatory mechanisms to influence tissue homeostasis. Understanding how NK cells respond to inflammation is crucial for comprehending their role in various diseases and their ability to recognize and respond to pathogens. Future studies will explore the temporal response of NK cells throughout the duration of an innate immune response.