Michigan Medicine Pediatric Research Symposium - 2022
University of Michigan, Department of Pediatrics
Welcome to the MM Department of Pediatrics 'Research Day' highlighting research in pediatric/children's health medicine at the University of Michigan.
Symposium (virtual) Activities:
8-9:00 AM "Preparing for the next 50 years after the time of COVID"
Pediatric Research Symposium/The Annual Valerie Opipari Endowed Lecture
R. Walker-Harding, MD, FAAP, FSAHM
University of Washington, Seattle Children's Hospital
12-1:00pm VIRTUAL POSTER SESSION (you are here)
This virtual poster session, which begins at 12:00 Noon, features work by students, residents, fellows, staff, and faculty. The posters/abstracts are numbered and categorized in tracks (basic science, clinical investigation, health services research, and quality improvement, medical education). To attend a virtual poster discussion, click on the 'chat' button during the poster session (12-1pm, May 24). A few posters feature a pre-recorded video presentation.
1-3:00pm PLATFORM/ORAL PRESENTATIONS
Join Zoom Meeting: https://umich.zoom.us/j/98914121266
More info: https://medicine.umich.edu/dept/pediatrics/research/annual-research-symposium
Filter displayed posters (69 tags)
01: Airway Bacterial Community Composition in Persons with Advanced Cystic Fibrosis Lung Disease
Christina S. Thornton1, Lisa A. Carmody1, Linda M. Kalikin1, Kristopher Opron2, Richard H. Simon2, Lindsay J. Caverly1 and John J. LiPuma1.
Objectives: We investigated the structure of airway bacterial communities in 190 pwCF with advanced lung disease with particular attention to the prevalence and relative abundance of bacteria that dominate airway communities and the associations these community structures may have with lung function.
Methods: We sequenced the bacterial 16S rRNA from sputum of 190 pwCF from the University of Michigan with advanced lung disease (percent predicted forced expiratory volume in 1 second (ppFEV1) <40%) to determine microbiome composition, prevalence, and relative abundance of dominant taxa (defined as the most abundant genus with at least twice the abundance of the second most abundant genus). Illumina MiSeq paired-end sequencing of the 16S rRNA V4 region was used to evaluate the airway microbiome. Statistical analyses were preformed using R v.4.1.1.
Results: Bacterial communities from 115 (60%) of 190 pwCF were characterized by low diversity and a dominant taxon. In most (90%), the dominant taxon was a canonical CF pathogen: Pseudomonas, Staphylococcus, Achromobacter, Stenotrophomonas or Burkholderia. Quantitative measures of bacterial load demonstrated no significant differences between advanced ppFEV1 groups dominant genera. Multivariable analysis (adjusted R2=0.282, F=28.9, p<0.0005) demonstrated increasing BMI, higher richness, highest relative abundance with MSSA or other taxon correlating with greater lung function. Conversely, higher dominance ratio, increasing number of antibiotics, higher relative abundance of the most abundant genera, and presence of exacerbation at time of sample collection was negatively correlated with lung function. PwCF with a low diversity community and dominant taxon had reduced lung transplant-free survival compared to those without (median survival of 1.6 yrs. vs 2.9 yrs.). Amongst dominant genera, those with Burkholderia had the lowest median lung transplant-free survival (0.95 years).
Conclusions: Although airway bacterial communities of most pwCF with advanced lung disease were characterized by the presence of a dominant taxon, a large minority (40%) were not. Most often, canonical CF pathogens dominated communities, but other genera were occasionally dominant. Higher relative abundance of dominant taxa was associated with adverse clinical outcomes. A better understanding of the antecedents of communities characterized by low diversity and the presence of a dominant species – and their impact on disease trajectory - may provide avenues to devise improved management strategies.
02: ETV6 DEFICIENCY AND MICROSATELLITE ENHANCERS DRIVE TRANSCRIPTIONAL DYSREGULATION IN B-LYMPHOBLASTIC LEUKEMIA
Joshua W. Goldman1, Rohan Kodgule2, Alexander C. Monovich2, Travis Saari2, Cody N. Hall2, Niharika Rajesh2, Juhi Gupta2, Athalee R. Aguilar2, Noah Brown2, Mark Y. Chiang3, Marcin P. Cieslik2, Russell J. H. Ryan2
Objectives: We sought to identify and functionally characterize cancer-specific regulatory elements that contribute to leukemogenesis in ETV6-RUNX1+ B-ALL.
Methods: We performed k-means clustering and motif analysis on H3K27ac ChIP-Seq and ATAC-Seq data from 26 B-cell cancer cell lines. Lentiviral transgenes were used to re-express wild-type or mutant ETV6 in ETV6-deficient B-ALL. CRISPR-interference (CRISPRi) was used for epigenetic silencing of GGAA microsatellite enhancers and to repress ERG gene expression. ChIP-Seq was used to map genome-wide ERG and ETV6 binding sites. qPCR and RNA-Seq were used to profile transcriptional changes due to ERG, ETV6, and GGAA repeat perturbation.
Results: Motif analysis identified strong enrichment for tandem repeats of the sequence “GGAA” in enhancers that were exclusively acetylated in four E-R+ B-ALL cell lines and the E-R-like cell line MUTZ5. Repeats with ≥6 tandem copies of “GGAA” were selectively acetylated and accessible in H3K27ac ChIP-Seq and ATAC-Seq datasets from primary patient samples of E-R+ B-ALL but not from other genetic subtypes that lack ETV6 aberrations. Re-expression of ETV6 in ETV6-deficient, E-R+ B-ALL cells led to significant growth inhibition. Restored ETV6 bound extensively to GGAA repeats, repressed repeat enhancer acetylation, and repressed expression of adjacent E-R+ signature genes. CRISPRi targeting of six GGAA repeat enhancers led to significant downregulation of their associated E-R+ signature genes, including EPOR and PIK3C3. GGAA repeat enhancers are a known driver of Ewing sarcoma, where they are activated by oncogenic fusions of the ETS activators FLI1 or ERG. Use of CRISPRi to knock down ERG, but not FLI1, led to significant downregulation of E-R+ signature genes in B-ALL. ChIP-Seq showed that the ERG binds nearly all active GGAA repeat enhancers in three ETV6-deficient B-ALL cell lines, but not in ETV6-intact B-ALL.
Conclusions: GGAA repeat enhancers, sustained by ETV6 deficiency and strong ERG expression, regulate the unique gene expression program in E-R+ B-ALL and other ETV6-inactivated B-ALL. Our findings may have crucial implications for E-R+ B-ALL modeling, as most GGAA repeats are not conserved between mice and humans. Mechanisms that activate leukemia-specific repeat enhancers may represent appealing targets for future therapeutic development.
03: IMMUNOPROTEASOME ACTIVITY IS REQUIRED FOR HOST DEFENSE AGAINST MURINE CORONAVIRUS RESPIRATORY INFECTION
Xiaofeng Zhou,1 Jacob C. Steigmann,2 Bethany B. Moore,1 and Jason B. Weinberg1,2
Objective: We used murine hepatitis virus strain 1 (MHV-1), a murine coronavirus, to test the hypothesis that increased IP activity during coronavirus infection drives immunopathology and manifestations of disease.
Methods: We infected susceptible C3H.HeJ mice intranasally with MHV-1. Mice were treated with ONX-0914 (ONX), a specific inhibitor of the β5i IP subunit, or vehicle every other day beginning on the day of infection. We monitored weight loss and survival following infection and harvested lungs and livers at multiple time points. We used RT-qPCR and Western blot to evaluate IP subunit expression. RT-qPCR was used to assay viral load and virus-induced cytokine expression. Recruitment of immune cells to the lungs was evaluated by flow cytometry. Accumulation of ubiquitinated protein in organs was evaluated using Western blot.
Results: MHV-1 infection upregulated expression of IFN- and IP subunits in lungs and livers. Viral replication was slightly higher in lungs and livers of ONX-treated mice at early time points, but IP inhibition did not prevent clearance of virus. However, IP inhibition significantly enhanced virus-induced weight loss and mortality during late stages of infection. Pharmacologic inhibition of IP activity with ONX suppressed lung expression of pro-inflammatory cytokines such as IL 17A, TNF-, and IL-1β but had no effect on IFN-β expression. IP inhibition reduced recruitment to the lungs of CD4 T cells, CD8 T cells, monocyte-derived alveolar macrophages, and type 1 conventional dendritic cells. IP inhibition had mixed effects in the liver, suppressing IL-17A expression, enhancing TNF expression, but not affecting IFN-β or IL-1β expression. Lastly, IP inhibition enhanced accumulation of ubiquitinated protein in infected mice, particularly in livers, at late times post infection.
Conclusions: Our results indicate that the IP is vital for host defense against MHV-1 respiratory infection. IP activity contributed to appropriate leukocyte recruitment and expression of pro-inflammatory cytokines, consistent with our hypothesis. However, IP inhibition enhanced, rather than reduced, manifestations of disease without increasing virus replication. We surmise that inhibition of other IP functions, such as degradation of poly-ubiquitinated and oxidant-damaged proteins that accumulate during infection, enhances manifestations of disease caused by acute MHV-1 infection.
04: CHD7, the causative gene for CHARGE syndrome, represses the transcription factor LHX1 to promote inner ear development
Jennifer M Skidmore, Anna M Graf, Jelka Cimerman, and Donna M Martin
05: Methods and Strategies to Modulate Expression of SCN1A for treatment of Dravet Syndrome
Jordan Safran*, Anna Loughman*, Grace Lin, Shivanshi Vaid, Louis T. Dang (*These authors contributed equally to this work.)
Objective: The SCN1A transcript has multiple upstream open reading frames (uORFs), which begin with “false” upstream AUG (uAUG) start codons that are 5’ of the primary AUG (pAUG) start codon. The presence of uAUGs can compete with the pAUGs for ribosomal translation, and this can result in decreased efficiency of translation from the pAUG. We hypothesize that targeting uORFs with antisense oligonucleotides (ASOs) in SCN1A will result in increased expression of NaV1.1.
Methods: We first constructed luciferase reporter plasmids that contained the uORFs and the initial coding sequence of SCN1A to quantify translation of the primary open reading frame (pORF). We disrupted the uORFs in our mutant plasmid by mutating the uAUGs of this reporter plasmid. The mutant and wild-type plasmids were used for luciferase enzyme assays after transfecting them into HEK293 cells or subjecting them to in vitro transcription and translation reactions. We designed ASOs to bind the three most proximal uORFs to the pORF and tested their effect on luciferase activity.
Results: When the four uAUGs most proximal to the pAUG were mutated, there was a 6.9-fold increase in luciferase expression in transfected HEK293 cells (p<0.0001). Individually mutating either of the two uAUGs most proximal to the pAUG increased luciferase activity by 1.5-fold (p<0.001). Treatment with individual and combinations of ASOs targeting the 4 uAUGs did not significantly increase luciferase activity in vitro.
Conclusions: The presence of uORFs interferes with translation from the pORF in SCN1A, and mutating the uAUGs increased pORF translation efficiency. This suggests that targeting uORFs in SCN1A is a viable therapeutic strategy in DS. Treatment with ASOs targeted to the uAUGs did not increase luciferase activity, leaving room for design optimization. The next iteration of this experiment in our lab will utilize an induced pluripotent stem cell (iPSC) line with a tag on the NaV1.1 protein to rapidly determine the quantity of NaV1.1 produced using luciferase assays.
06: RHINOVIRUS-A1B DECREASES CORONAVIRUS NL63 REPLICATION AND INFLAMMATION IN HUMAN ACE2-EXPRESSING MICE.
J. Kelley Bentley, Haley A. Breckenridge, Jordan E. Kreger, Shilpi Singh, Adam M. Goldsmith, Carey N. Lumeng, and Marc B. Hershenson.
Supported by National Institutes of Health grants AI120526 and AI155444.
07: HYPERMYELINATION OF CRANIAL NERVE VIII IN A MOUSE MODEL OF CHARGE SYNDROME
K. Elaine Ritter1, Sloane M. Lynch2, Ashley M. Gorris2, Lisa A. Beyer3, Lisa L. Kabara3, Yehoash Raphael3, Donna M. Martin1,4
08: IDENTIFICATION OF SINGLE NUCLEUS RNA TRANSCRIPTS IN BRAIN REGIONS CRITICAL FOR ENERGY HOMEOSTASIS
AG Diamant1, A Rupp2, DP Olson1
10: SOX2 AND CHD7 COOPERATE TO REGULATE DEVELOPMENT OF THE INNER EAR
Jingxia Gao, Jelka Cimerman, K. Elaine Ritter, Jennifer M. Skidmore, Donna M. Martin
11: ZERO-WASTE MOLECULAR DIAGNOSTICS FROM BIOPSY NEEDLE WASH WATER
Jack Wadden1, Vishal John1, Kait Verbal2, Amy Bruzek2, Wajd-Al-Holou2, Jason Heth2, Hugh Garton2 and Carl Koschmann1.
12: Epidemiology and clinical outcomes of airway infection with Pseudomonas species other than P. aeruginosa in cystic fibrosis
Nada H Youssef1, MD, Madsen Zimbric1, Lindsay J. Caverly1
13: THE ACTIVATING NKG2D RECEPTOR MEDIATES NEONATAL LUNG INJURY INDUCED BY CHRONIC EXPOSURE TO BACTERIAL ENDOTOXIN: IMPLICATIONS FOR BRONCHOPULMONARY DYSPLASIA
Cui TX, Zhang YJ, Anderson C, Popova AP,
14: EXPOSURE TO A REAL-LIFE ENVIRONMENTAL CHEMICAL MIXTURE ALTERS THE METABOLITE PROFILE IN THE PLASMA OF SHEEP: AN UNTARGETED METABOLOMICS STUDY
Thangaraj SV1, Kachman M2, Bellingham M3, Sinclair KD4, Lea R4, Evans NP3 and Padmanabhan V1.
15: SOX11 AND CHD7 ACT IN THE SAME GENE REGULATORY NETWORK TO PROMOTE INNER EAR DEVELOPMENT
Jelka Cimerman1, Ethan D. Sperry2,5, Ronus Hojjati3, Donald L. Swiderski4, Yehoash Raphael4, and Donna M. Martin1,2,4
16: MATERNAL MEDITERRANEAN DIET ADHERENCE DURING BREASTFEEDING IS ASSOCIATED WITH INFANT ADIPOSITY
Aria Grabowski1, Lindsay Ellsworth2, Jacqueline Richardson3, Ana Baylin1,3, Alison Miller4, Ashley Gearhardt5, Katharine Rosenblum6, Julie Lumeng7, and Brigid Gregg8
Objectives (1) Evaluate the relationship between maternal MedDiet adherence and infant growth during lactation. (2) Determine associations between maternal diet and milk composition. (3) Determine associations between milk composition and infant growth.
Methods This study utilized data from the ABC mother-infant dyad cohort, a longitudinal study on maternal feeding practices. Dyads were enrolled at 2 weeks or 2 months of age and followed until 12 months. Mothers completed a validated food frequency questionnaire (FFQ) from which the MedDiet score was calculated, and energy-adjusted nutrient intake was calculated. Expressed human milk samples were collected and macronutrient analysis was completed using mid-infrared transmission spectroscopy (MIRIS Human Milk Analyzer). The following markers were measured for infant growth: weight, length, and flank skinfold thickness (ST) at each visit. Spearman correlations were calculated between maternal diet factors, infant growth, and milk composition. Correlations were then stratified by breastfeeding exclusivity (exclusive or mixed fed) based on breastfeeding intensity ratio calculated by the number of human milk feeds (average per week) divided by the total number of liquid feeds at 2 months. Infants were excluded from analysis if exclusively formula fed.
Results 161 dyads were included in the analysis. Maternal carbohydrate intake was negatively associated with weight-for-age Z score (WAZ) at 2 months (R:-0.14, p=0.08). MedDiet was negatively associated with ST at 2 months (R:-0.18, p=0.03) and 6 months (R:-0.160, p=0.07) and positively associated with WAZ at 2 months (R:0.13, p=0.09). When stratified by exclusively breastfed (n=125) or mixed-fed (n=36), MedDiet is negatively associated in only exclusively breastfed infants for ST at 2 months (R:-0.26, p: 0.005) and 6 months (R:-0.21, p=0.03). Further, at 2 months in exclusively breastfed infants, length-for-age Z score was positively associated with saturated fat intake (R:0.18, p=0.05) and WAZ was negatively associated with carbohydrate intake (R:-0.19, p=0.03). Evaluation of milk composition showed that maternal dietary fat types was negatively associated with milk protein content. There were no significant associations between milk composition and infant growth.
Conclusions Maternal dietary intake is associated with infant growth and human milk composition. Maternal Mediterranean diet adherence is associated with lower infant adiposity at 2 months and 6 months for exclusively breastfed infants.
19: Deep Mutagenesis Scan of SERPINC1 to inform variants affecting thrombosis risk.
Christopher Bidlack, Krista Golden, Mary Underwood, and Karl Desch
Objectives Since AT deficiency is a strong risk factor for VTE, a comprehensive functional database of SERPINC1 variants could guide the interpretation of sequencing results in VTE patients and lead to a better understanding of AT structure and function.
Design/Methods To perform a deep mutational scan, we will transfect the variant SERPINC1 cDNA library into cells bearing the Bxb1-based recombinase “landing pad” system described by Matreyek et al. To identify variants causing AT retention, we will tag our segmented SERPINC1 libraries with eGFP reporter genes (AT-eGFP), and subject our cells to fluorescence-activated cell sorting (FACS) followed by next gen sequencing to identify variants associated with poor AT secretion. To identify variants affecting antithrombin function we will add a transmembrane domain of glycophorin B (GYPB) instead of the c terminal eGFP tag (AT-GYPB). This will allow us to perform antithrombin functional screens using flow cytometry. Specifically, we will treat library cells with thrombin or factor Xa, two canonical ligands of antithrombin, to determine which variants disrupt AT function. Thrombin-Antithrombin (TAT) complex ELISA has confirmed the functionality of our SERPINC1-eGFP construct, and Sanger sequencing has confirmed successful mutagenesis of eight known SERPINC1 variants.
Results and Conclusions We have currently developed AT-eGFP which retains its functional inhibition of thrombin. We are also developing AT-GYPB and validating its ability to form inhibitory complexes. Efforts are underway to separate variants in SERPINC1 associated with poor secretion from reference and other functional variants. Our next steps also involve full library cloning and screens. Any variants found to affect AT secretion or function will be used to make a functional map to find mutational clustering patterns.
AIRWAY TUFT/BRUSH CELLS ARE REQUIRED FOR EXAGGERATED TYPE 2 INFLAMMATION AND MUCOUS METAPLASIA IN IMMATURE MICE UNDERGOING HETEROLOGOUS RHINOVIRUS INFECTION.
Haley A. Breckenridge, Mingyuan Han, Yiran Li, Daniel Sawicky, Adam M. Goldsmith, J. Kelley Bentley, Ichiro Matsumoto and Marc B. Hershenson
Supported by National Institutes of Health grants AI120526 and AI155444.
31: THERAPEUTIC TARGETING OF PRENATAL PONTINE ID1 SIGNALING IN DIFFUSE MIDLINE GLIOMA
Dana Messinger1^, Micah K. Harris1^, Jessica R. Cummings1, Chase Thomas1, Tao Yang1, Stefan R. Sweha1, Rinette Woo2, Robert Siddaway3, Martin Burkert4, Stefanie Stallard1,Tingting Qin1, Brendan Mullan1, Ruby Siada1, Ramya Ravindran1, Michael Niculcea1, Abigail Dowling1, Joshua Bradin1, Kevin F. Ginn6, Melissa A.H. Gener6, Kathleen Dorris7, Nicholas A. Vitanza8, Susanne V. Schmidt9, Jasper Spitzer9, Jiang Li10, Mariella G. Filbin10, Xuhong Cao1, Maria G. Castro1, Pedro R. Lowenstein1, Rajen Mody1, Arul Chinnaiyan1, Pierre-Yves Desprez2, Sean McAllister2, Matthew D. Dun11, Cynthia Hawkins3, Sebastian M. Waszak4,5, Sriram Venneti1, Carl Koschmann1*, and Viveka Nand Yadav1*
Objective: This study aims to uncover the role ID1 plays in the invasive and migratory phenotypes of DMG, as well as determining its therapeutic targetability.
Methods: Whole exome, RNA, and ChIP-sequencing was performed on the ID1 locus in DMG tissue. Scratch-assay migration and transwell invasion assays of cultured cells were performed following shRNA-mediated ID1-knockdown. In vitro and in vivo genetic and pharmacologic [cannabidiol (CBD)] inhibition of ID1 on DMG tumor growth was assessed. Self-reported CBD dosing information was collected from DMG patients.
Results: Increased ID1 expression in human DMG and in utero electroporation (IUE) murine tumors is associated with H3K27M mutation and brainstem location. ChIP-sequencing indicates a similar epigenetically active state at ID1 regulatory regions in human H3K27M-DMG tumors and prenatal pontine cells. Higher ID1-expressing astrocyte-like DMG cells share a transcriptional program with oligo/astrocyte-precursor cells (OAPCs) from the developing human brain and demonstrate upregulation of the migration regulatory protein SPARCL1. Genetic and pharmacologic (CBD) suppression of ID1 decreases tumor cell invasion/migration and tumor growth in both murine IUE and multiple patient-derived (DIPG007 and DIPGXIIIP*) in vivo models of DMG. Finally, we analyzed the dose of self-reported CBD treatment in DMG patients.
Conclusions: Our study identifies that H3K27M-mediated re-activation of ID1 in DMG results in a SPARCL1+ migratory transcriptional program that is therapeutically targetable with CBD.
20: PEANUT-INDUCED FOOD PROTEIN INDUCED ENTEROCOLITIS
Kylie Jungles and Malika Gupta
21: CONTEMPORARY OUTCOMES OF TRACHEOSTOMY IN PATIENTS WITH SINGLE VENTRICLE HEART LESIONS
Dominic Zanaboni; Sunkyung Yu; Ray Lowery; Carolyn Vitale; Kurt R. Schumacher;
22: PARENT-REPORTED SLEEP PROFILE FOR CHILDREN WITH EARLY-LIFE EPILESIES
Gupta G1, Dang LT1, O’Brien LM1, Shellhaas RA1
METHODS: Participants registered with the Rare Epilepsy Network (REN) were queried about sleep via online questionnaires. Descriptive statistics and logistic regression were performed.
RESULTS: Median age of the 356 children was 56 months (interquartile range 30 to 99), 56% were female, and 53% (188/356) endorsed a sleep concern. Frequent nighttime awakenings (157 of 350; 45%), difficulty falling asleep (133 of 350; 38%), and very restless sleep (118 of 345; 34%) were most endorsed. Nocturnal seizures were associated with sleep concerns and were reported in 75% (268 of 356) of children. Of the children with nocturnal seizures, 56% (118 of 268) had sleep concerns. Of the children without nocturnal seizures, 43% (38 of 88) had sleep concerns. Sleep concerns were most common in dup15q syndrome (16 of 19; 84%). Children aged 4 to ≤ 10 years (adjusted odds ratio [aOR] 16.1; 95% confidence interval [CI] 2.0,131.0) and 10 to <13 years (aOR 22.2; 95% CI 2.6, 188.6) had a greater odds of having a sleep concern compared with children aged ≤ 6 months. Female sex appeared protective for sleep concerns (aOR 0.6; 95% CI 0.4, 0.9). The association between sleep concerns and nocturnal seizures was weaker when adjusted for sex and age category in a logistic regression model. CONCLUSIONS: The most commonly reported sleep concerns for children with ELE were similar to those of healthy children. Restless sleep, prolonged sleep latency and frequent nocturnal awakenings persisted in children with ELE, in contrast to the natural progression of sleep consolidation expected in healthy children. This could reflect altered neurodevelopment or untreated sleep pathology in children with ELE. Nocturnal seizures may compound these sleep concerns.
23: CHARACTERISTICS OF SPECIALTY PALLIATIVE CARE UTILIZATION IN CHILDREN WITH HIGH GRADE GLIOMA WHO ENROLL ON CLINICAL TRIALS VERSUS THOSE WHO DO NOT
Holly J. Roberts, Andrea Franson
24: MATERNAL METABOLIC HEALTH AND PERINATAL FACTORS INFLUENCING PRETERM INFANT BODY COMPOSITION AT HOSPITAL DISCHARGE
Lindsay Ellsworth1, Subramaniam Pennathur2
Funding Support & Acknowledgements: M-Diabetes Clinical/Translational Research Scholar, MNORC P30DK089503.
25: Neonatal Lung Mesenchymal Stromal Cells as Early-Life Predictors of Asthma in Survivors of Prematurity
VanBeckum, DR1, Kaciroti N2, Cui TX1, Popova AP1
26: Reproductive Counseling in Women with Congenital Heart Disease: A survey of primary care provider comfort and knowledge
Kristin N Andres, Mark D Norris, Justine Wu
Objective A survey was performed to assess the current comfort of PCP managing reproductive health for women with CHD as well as their ability to provide evidence based contraceptive options and family planning counseling.
Methods A survey was distributed to a convenience sample of PCPs treating reproductive-aged women at the University of Michigan.
Results The final sample included 163 providers (response rate= 47%), 43% of whom reported currently caring for premenopausal women with CHD. Although half (46%) of respondents felt they should take primary responsibility for reproductive counseling in women with CHD the majority (86%) were uncomfortable discussing pregnancy risk, and only half (54%) felt comfortable providing basic contraceptive counseling to these patients. Few providers felt they had the knowledge necessary to provide individualized contraception (46%) or pregnancy risk (10%) counselling. Providers were more likely to prescribe a medically contraindicated form of contraception to a hypothetical patient with simple CHD (57%) compared to one with a complex cardiac lesion (30%) and few respondents identified all medically appropriate forms of contraception for these patients (15% and 25% respectively). Clinicians were also more likely to underestimate the risk of pregnancy in a patient with simple CHD compared to one with complex CHD (25% and 10% respectively).
Conclusion PCPs have low degrees of comfort addressing reproductive health concerns in women with CHD and knowledge gaps which are a barrier to providing medically appropriate care. Interestingly, women with simple CHD were more likely to receive medically inappropriate counselling. Further education of PCPs could enhance provider comfort and improve patient care.
27: INTESENSORY INTEGRATION IN INFANTS WITH AUTISM SPECTRUM DISORDER
Pooja Rao; Michael Lewis
Methods To measure infants' sensitivity to audiovisual synchrony, subjects around 4-5 months of age, sat in front of two screens playing a video of a woman articulating the syllable /ba/. The experiment consisted of 20 trials that were each 20 seconds each. On one screen, the audio matched the women’s lip movement. On the other discrepant screen, the same events were presented at increasing levels of audio-visual asynchrony (333 ms, 500 ms, 666 ms, 833 ms, and 1000 ms), with the sound always preceding its corresponding visual event. To ensure there were no external variables, the matching, and discrepant videos were displayed on the left and right sides in a randomized order in each trial. Infants were also given one of two conditions that randomized the trial order in which the delay binding windows were displayed. Our lab developed a coding program to quantify the number of seconds the infant spent looking at the matching screen, discrepant screen, or looking away from the screen.
Analysis We first assessed whether individual subjects spent a more extended time looking at the matching screen or the discrepant screen. Typically developing subjects (n=56) spent an average of 6.33 seconds out of a 20 seconds trial looking at the matching screen. Subjects At-Risk for ASD (n=14) spent an average of 6.43 seconds out of 20 seconds of trials looking at the matching screen. Compared to the average time spent looking a the discrepant screen, both typically developing and at-risk subjects spent more time looking at the matching screen than the discrepant screen for all temporal binding windows. Next, we measured each subject’s preference of looking at the matching side versus the discrepant side for different delay windows. The delay window in which infants exhibited their most extended look duration indicates the individual sensitivity in their audio-visual temporal binding window. On average, typically developing subjects spent the most time looking at the matching screen at the 0.500 second Delay Binding Window. At-Risk spent more average time looking at the matching screen at the 1.000 second Delay Binding Window.
28: DESCRIBING SESAME SENSITIZATION PATTERNS IN INFANTS AND TODDLERS
Freigeh, George E1, Khokar, Dilawar2, Sanders, Georgina2,3, Gupta, Malika2,3
29: Cutting Ties With an Old Friend: Omphalitis and Bacteremia With Umbilical Cord Nonseverance
Lydia Lannia, Katherine Panninga, Kimberly K. Monroeb, Maria Skoczylasb, Derek Spindlerb
References 1. Ittleman, BR; German, KR; Scott, E; Walker, V; Flaherman, VJ; Szabo, J; Beavers, JB. “Umbilical Cord Nonseverance and Adverse Neonatal Outcomes.” Clinical Pediatrics. 2019. 58(2), 238–240. 2. Tricarico, A; Bianco, V; Di Biase, AR; Lughetti, L; Ferrari, F; Berardi, A. “Lotus birth associated with idiopathic neonatal hepatitis.” Pediatrics & Neonatology. 2016. 58(3), 281–282. Article, TAIPEI: Elsevier B.V. 3. Monroe, KK; Rubin, A; Mychaliska, KP; Skoczylas, M; Burrows, HL. “Lotus Birth: A Case Series Report on Umbilical Nonseverance.” Clinical Pediatrics. 2019. Vol. 58(1) 88–94
30: THE A-WORD, BLACK BOXES, AND LABYRINTHS: HOW PCPS THINK AND FEEL ABOUT AUTISM CARE IN THE MEDICAL HOME
Nicole Hamp (a), Sarah DeHaan (b), Celina Cerf (c), Jenny S. Radesky (a)
Objective: We aimed to explore pediatric PCP experiences and needs around identification and management of ASD in toddlers as an initial phase of implementing a tiered ASD evaluation system at a large midwestern academic medical center.
Methods: We recruited 28 PCPs to take part in semi-structured interviews via Zoom. Probe questions elicited opinions about current screening and referral procedures; experiences obtaining services for patients; effective communication with parents; physician emotional experience when introducing ASD concerns; practice-based sources of disparities; and larger needs for ASD management in the primary care setting. All interested MM pediatric PCPs were eligible to take part. Interview transcripts were analyzed qualitatively by a multi-specialty research team for recurrent themes using grounded theory analysis.
Results: Participants were 89% female, ranging in clinical experience from <1 year to >27 years, representing all 8 pediatric primary care clinic sites at our institution. Dominant themes relating to the PCP’s cognitive, emotional, and relational experience of caring for patients with ASD were identified, which reflected the trajectory of ASD identification, management, and related medical decision making (Table 1).
Conclusions: Existing literature and results from this study suggest a need for targeted improvements in primary care to: (1) increase PCP capacity and confidence in communicating concerns of ASD with families, (2) refer for timely diagnostic evaluations in trusted and easy-to-navigate care systems, and (3) increase family activation and capacity to follow up on ASD evaluation and treatment services. Findings will inform the design of a tiered ASD evaluation pilot study at our institution.
32: Capacity for Regulation of Energy Intake in Infancy
Lyndsey AF. Reynoldsa, Harlan McCafferyb, Danielle Appugliesec, Niko A. Kacirotid, Alison L. Millere, Katherine L. Rosenblumf, Ashley N. Gearhardtg, Julie C. Lumengb,h
Methods: Infant capacity for REI was measured at 2 wks, 2, 4, 6, 9, and 12 mos in healthy, full-term infants. For 6 hours, the caregiver fed the infant ad lib on day one (“typical”(TYP)), and hourly on day two (“increased frequency”(INC)). Intake was measured using pre- and post- bottle weights and maternal report of solids. Capacity for REI was indexed as the percent increase in intake and as the difference in intake in kilocalories per kilogram (kcal/kg) infant body weight, between the INC vs. TYP protocols; a value of zero in either index indicates perfect REI. Infant and caregiver characteristics were obtained by questionnaire and infant anthropometry measured. Trajectory analysis was used to determine: (1) if there are, on average, individual differences in the capacity for REI; (2) if the capacity for REI changes with age; and (3) if the capacity for REI differs by feeding type (milk only (MO), solids only (SO), or milk and solids combined (MS)).
Results: The sample (n=186 infants, 1184 feedings) was 50% male, 61% white, 15% black, 7% Hispanic; mean gestational age 39.5 wks (SD 1.1), birthweight 3.4 kg (SD 0.4), and 12 mo weight-for-age z-score 0.1 (SD 0.9). On average, an additional 2.2 to 2.7 feedings (across ages) were given in the INC vs. TYP protocols. Total kcal consumed from MS ranged from 165 (SD 74) at 2 wks to 336 (SD 225) at 12 mos (TYP) and 164 (SD 86) to 335 (SD 192) (INC). Trajectory analysis indicated a single trajectory for both indices (for MO, SO, and MS), indicating no evidence for individual differences. For the index that was the percent increase in intake in the INC vs. TYP protocols for MS, the estimate at 2 wks was 0.167% (95% CI [-0.005, 0.339], p = .057) and slope -0.185 (95% CI [-0.146, 0.516], p = .273). For the index that was the difference in intake in kcal/kg in the INC vs. TYP protocols for MS, the estimate at 2 wks was 2.76 kcal/kg (95% CI [0.166, 5.36], p = 0.037) and slope -0.299 (95% CI [-5.28, 4.68], p = 0.906). This indicates nearly perfect REI that did not change with age. The findings did not differ for MO, SO, or MS.
Conclusions: To our knowledge, this is the first study to objectively measure REI in healthy full-term infants across 6 age points in the first 12 mos of infancy. On average, infants have the capacity for precise energy regulation for both milk and solids from ages 2 wks to 12 mos.
34: IMPROVED RISK STRATIFICATION OF PEDIATRIC FEBRILE NEUTROPENIA EPISODES USING A NOVEL CLINICAL TOOL WITH PROCALCITONIN: INTERNAL ANALYSIS PRIOR TO IMPLEMENTATION
Nate Nessle DO1, Tom Braun PhD2, Sung Choi MD MS1, Rajen Mody MD MS1
Primary Aim: The primary aim of this study was to describe our single institution experience of the non-interventional, internal evaluation of a recommended clinical risk tool alone and in combination with serial procalcitonin prior to local implementation: an important, “required” step recommended by the International Fever and Neutropenia Guideline Panel and Children’s Oncology Group (COG).
Methods: The evaluated novel risk tool, termed study decision rules (SDR), incorporated serial procalcitonin with a modified, more restrictive clinical risk tool (Alexander, et al.) recommended by the COG. The study standard-risk (SSR) group met clinical standard-risk criteria with two serial procalcitonin <0.4 ng/mL; median time from fever onset for each procalcitonin value was 2 and 16 hours, respectively. The study high-risk (SHR) group met clinical high-risk criteria or clinical standard-risk with a procalcitonin ≥0.4 ng/mL. Severe events were defined as blood stream infection (BSI), intensive care unit (ICU) admission, or death. Descriptive and bivariate statistics compared the groups and outcomes.
Results: In 608 FN episodes, the clinical risk tool alone identified 39.1% (238/608) clinical standard-risk episodes; 5.9% (14/238) had severe events. Prospectively using the SDR, the SHR group included 76.6% (92/120) of episodes; severe events occurred in 20% (3/15) of clinical standard-risk episodes included in the SHR group due to elevated procalcitonin ≥0.4 ng/mL. The SHR group had significantly more BSI [21.7% (20/92) vs. 0% (0/28); P= 0.007] and ICU admissions [13% (12/92) vs. 3.6% (1/28); P= 0.158]. This group also had significantly fewer short hospital stays < 3 days [17.4% (16/92) vs. 60.7% (17/28); P= <0.001].
Conclusion: The modified clinical risk tool in our institution has similar performance to prior validation studies. However, the novel SDR with serial procalcitonin aided in identifying severe events in clinical standard-risk episodes, but analysis was limited. Institutions may consider similar internal evaluation methodology before FN episode risk stratification.
35: SUSPECTED MIS-C ADMISSIONS FROM EMERGENCY DEPARTMENT TO INPATIENT UNIT: A REVIEW
Budnik, Elizabeth,1 Chang, Y Katharine,2 Mikesell, Christine,2 Pomeranz, Elaine1,2
Objectives: To identify children undergoing MIS-C evaluation and to determine if using only laboratory criteria to make admission decisions resulted in the hospitalization of well-appearing children who could have been managed on an outpatient basis.
Design/Methods: We performed a retrospective chart review of patients 18 years and under who presented to Children’s Emergency Services between February 2020 and March 2021. Patients were included if they had a ferritin obtained in the Emergency Department (ED) and were admitted to the pediatric hospital medicine (PHM) service. Manual chart review was then conducted to determine if ferritin was obtained as part of a MIS-C workup, if patients met other admission criteria, if they were well-appearing based on clinical documentation, if they required further intervention for Kawasaki disease (KD) or MIS-C, or if they required escalation of care within 48 hours of admission. Final diagnoses were also recorded.
Results: We identified 59 well-appearing patients who underwent MIS-C evaluation and were admitted to the PHM service. Of those, 58 patients met at least one other criterion for admission (eg, inability to tolerate oral fluids, fever of unknown origin, concern for malignancy); 5 were treated for MIS-C or Kawasaki Disease (KD); and 4 patients required escalation of care (supplemental oxygen, transfer to the PICU, or rapid response team call) within 48 hours of admission. One patient with urinary tract infection could have been managed with outpatient antibiotics. The most common discharge diagnosis was viral illness.
Conclusions: While we hypothesized that well-appearing children were being admitted due to abnormal labs alone, our study did not find this to be the case. Only one patient who could have been discharged from the ED was admitted because of abnormal MIS-C labs. All other admitted patients undergoing MIS-C evaluation also met additional admission criteria and would not have been discharged regardless of the lab results. We conclude that abnormal MIS-C screening labs are correlated with clinical illness appropriate for hospitalization, and neither result in excess admissions nor facilitate disposition from the ED.
36: THE RELATIONSHIP BETWEEN ESTROGEN AND SUBSEQUENT GROWTH RESTRICTION AMONG ADOLESCENTS WITH HEAVY MENSTRUAL BLEEDING
Jessie M Hoxie1, Sarah D Compton1, Mina M Farahzad2, Olivia K Winfrey2, and Monica W Rosen2.
37: THE REPRODUCIBILITY AND RELIABILITY OF INSULIN RESISTANCE INDICES IN CHILDREN AND ADOLESCENTS
Nellie Said; Mary Ellen Vajravelu; Jennifer L. Meijer; Joyce Lee
Background: Insulin sensitivity and secretion indices can be useful tools to better understand insulin homeostasis in children and adolescents who are at risk for developing diabetes. There have been studies in the adult population comparing various indices against OGTT’s and insulin clamp testing, but there have not been studies examining the reproducibility and reliability of these measures in adolescents.
Methods: We performed two formal 2 oral glucose tolerance tests (OGTTs) in overweight (BMI ≥85th%, n=189) and normal weight (BMI <85th%, n=93) children within a 3-week period. We calculated multiple measures of insulin sensitivity - Homeostasis model assessment of insulin resistance (HOMA-IR; ((G_0*I_0 ))/22.5), WBISI Whole body sensitivity index (WBISI; 1000/√(〖(G_0*I_0 )*(G_mean*I_mean )〗^ )), Quantitative Insulin sensitivity Check Index (QUICKI) - 1/(log(I_0 )+) log(G_0 ), 1/fasting insulin levels, Fasting glucose to insulin ratio (FGIR). We also calculated measures of insulin secretion - Insulinogenic index (IGI; (ΔI_0,30)/Δ G_0,30), Homeostasis Model Assessment of beta cell function (HOMA-B; ((20*I_0 ))/((G_0-3.5) )) and disposition index (IGI x WBISI). We assessed the reproducibility of the indices between the first and second visits. We also compared the correlation coefficients of each fasting measure against each non-fasting measure overall, in the overweight/obese group, and in the normal weight group. Finally, we compared the correlation coefficients based on weight category, sex and race.
Analysis was done using R version 4.0.5 and the package cocor. Spearman correlations of first and second measurements were calculated for each sensitivity and secretion test. Fisher’s z-transformation was used to compare the correlation coefficients for the first and second measurements of overweight/obese to control, male to female, and white to black subsamples (Fisher 1925). Correlation coefficients of first and second measurements of the different tests were compared using the method of Dunn and Clark (1969).
Results: The non-fasting insulin sensitivity measurement (WBISI) was significantly more reproducible than all fasting measures overall and in the overweight/obese cohort. In the control group, WBISI was significantly more reproducible than HOMA-IR and QUICKI. However, there was no significant difference in reproducibility between WBISI and FGIR & 1/fasting insulin. Fasting insulin sensitivity measures were significantly more reproducible in the overweight & obese cohort compared to the normal weight cohort. There were no significant differences in the reproducibility of insulin secretion measures or non-fasting insulin sensitivity measures for overweight & obese vs. normal weight. There were no significant differences in the reproducibility of insulin secretion and insulin sensitivity measures for male vs. female groups and white vs. black individuals
Conclusions: Non-fasting insulin sensitivity measures are more reproducible than fasting insulin sensitivity measures, regardless of weight category. Insulin secretion measures have poor reproducibility overall and by weight category. Sex (male vs. female) and race (white vs. black) do not impact the reproducibility of insulin sensitivity and secretion measures.
38: INTEGRATIVE OMICS APPROACH TO INVESTIGATE MATERNAL BMI AND INFLAMMATION IN PREGNANT BLACK WOMEN
Nadia Saadat1, Todd A. Lydic2, Vasantha Padmanabhan1, Christopher G. Engeland3, Dawn Misra2, and Carmen Giurgescu4
39: Code status variation through four surges of COVID-19 pandemic at University of Michigan
Lily Rodgers, Blair Lenhan, Katie Epler, Tom O’Callaghan, Natalia Painter, Allison Bloom, and Emily Jacobson.
Methods: We reviewed the code status of adult patients (>18 years old) admitted to the University of Michigan with a positive COVID-19 test using electronic medical records. Data was retrospectively collected from March 2020 to December 2021 with patients separated into admission during 4 time periods correlating to COVID-19 surges (1st surge 3/1-9/31/2020, 2nd surge 10/1/20-2/28/22021, 3rd surge 3/1-7/30/2021, and 4th surge 8/1-12/31/2021). Patient characteristics and outcomes were collected along with code statuses during admission. Data was compared with sample t-test, ANOVA and Chi square tests.
Results: A total of 3187 patients met inclusion criteria. Patients admitted in the first two surges were more likely to be older than those in later surges and those admitted during the second surge had higher average comorbidity score. Similarly, those admitted during the first surge had longer length of stay along with ICU requirement compared to all other surges. Comparing initial code status preference between surges, over time there was a decreased percentage of those with DNAR/partial code status (16.6% vs 15.3% vs 8.3% vs 11.3%, p<0.001) along with increased percentage without a code status order (13.8% vs 18.6% vs 21.5% vs 23.0%, p<0.001). This same trend was observed with final code status at discharge, in addition to increased percentage with full code in the third surge (60.4% vs 60.9% vs 67.8% vs 61.5%, p=0.01).
Discussion: As expected, there was a decrease in those electing DNAR or partial code status preference over time. Interestingly, providers were less likely to order code statuses over time. There may be multiple reasons for this including increasing community spread but decreased virulence resulting in increased admissions with COVID-19 but not secondary to it. This is a limitation of our study, as it is unknown how many of these patients would have preferred a code status other than full. Our next step will be to perform multi-variable analysis looking at how age, co-morbidities, and vaccine status may have affected code status.
40: INFANTS WITH SEVERE CONGENITAL RENAL ANOMALIES ARE AT INCREASED RISK FOR DEVELOPMENTAL DYSPLASIA OF THE HIP
Gretchen Stepanovich1, Ashlee Smith2, Aunum Akhter1, Julie Sturza3, Rebecca Vartanian1, Matt Stepanovich4
41: Outcomes Following Biventricular Repair Of Atrioventricular Septal Defect With Single Left Ventricular Papillary Muscle
Scarlet Woodrick, Carlen Fifer, Jennifer Romano, Kellianne Kleeman, Ray Lowery, Sunkyung Yu
42: A RETROSPECTIVE STUDY ON CAUSE OF DEATH DUE TO HIGH-GRADE GLIOMAS IN PEDIATRIC VS ADULT PATIENTS
Samantha Lyons, Larry Junck, Andrea Franson
Objectives We hypothesized that patients with midline tumors of the brainstem, which is primarily seen in the pediatric population, die through brain/brainstem failure. For adults, we hypothesized that patients with HGG would die from brain failure, with or without brainstem involvement. We predicted that cause of death for a subset of patients is related to hydrocephalus and subsequent herniation resulting from tumor growth. Lastly, we expected that there may be patients with HGG who die from causes not directly related to tumor progression, such as systemic infection or radiation necrosis.
Design/Method We conducted a retrospective review of pediatric patients with grade 4 glial tumors or adults (>18 years of age) with grade 2 glial tumors that transformed into grade 3 or grade 4 tumors, or grade 3 or grade 4 tumors at diagnosis at or after 1/1/2016 at Michigan Medicine (HUM00208443). We collected demographic information and analyzed medical records and brain imaging within 3 weeks of death to assess characteristics relevant tol impression of cause of death.
Results Fifty-one pediatric patients were identified; 26 of which met inclusion criteria. Adult patient review remains ongoing with 43 patients included thus far. Initial data analysis reveals that the majority of pediatric and adult patients with HGG died from tumor progression and subsequent neurologic failure as opposed to to brainstem herniation. Additionally, there appears to be a greater use of palliative care and hospice in the pediatric population, with adults minimally using or being referred to palliative care at any time following HGG diagnosis. Pediatric patients at Michigan Medicine are almost always supported by Child and Family Life services; however, psychological support services are rarely provided or even offered to adult patients. Hospice is also involved closer to time of death in adult patients compared to pediatric patients.
Conclusion Data analysis is ongoing, though current data trends indicate opportunities for changes in practice and culture to ease the suffering of all patients with HGG through patient and provider education for end-of-life preparations.
43: CHARACTERIZATION OF CODE STATUS ORDERS IN ADULT PATIENTS ADMITTED WITH COVID-19 INFECTION
homas O’Callaghan, Katharine Epler, Blair Lenhan. Natalia Painter, Julie Barrett, Emily Jacobson
44: FREQUENCY OF POUCHITIS AFTER COLECTOMY AMONG PEDIATRIC PATIENTS WITH ULCERATIVE COLITIS
Seth Iskowitz, Samir K. Gadepalli, Anita Sharma, Jeremy Adler
Objectives We sought to evaluate the incidence and outcomes of pouchitis in pediatric patients with UC who underwent IPAA.
Design/Method We identified all patients at our institution with UC who underwent a proctocolectomy with IPAA from June 2013 through December 2020 via endoscopic software database and prospectively maintained patient registry. Inclusion began at ostomy take-down (or IPAA if no ostomy). We excluded patients with IPAA for reasons other than UC. The primary outcome was the development of pouchitis that was diagnosed clinically at any time after colectomy. The secondary outcome was endoscopically diagnosed or confirmed pouchitis. The study was granted waiver of consent from the IRB.
Results Among the 77 patients with UC who underwent an IPAA, 69% (53/77) were clinically diagnosed with pouchitis at least once during the study timeframe. In total, 61% (47/77) underwent endoscopic evaluation (for any indication). 85% (40/47) of those who underwent endoscopic evaluation were confirmed to have pouchitis. 13% (6/47) of those who underwent endoscopy were found to have Crohn’s disease (5/6 had pouchitis). In total, 62% (48/77) of patients were clinically or endoscopically diagnosed pouchitis. At least 6 more patients were found to have Crohn’s disease (8% of 77).
Conclusions In this study spanning 7 years, nearly 2 in 3 pediatric patients with UC and IPAA were diagnosed with pouchitis at least once. Of those, nearly 90% responded poorly to initial therapy leading to endoscopic evaluation. Larger studies in pediatrics are needed to corroborate these findings. Most importantly, evidence-based strategies are needed to predict and prevent pouchitis in order to improve quality of life for children with UC post-colectomy with IPAA.
45: INFANT SUCKING IN RESPONSE TO A CHALLENGING NIPPLE AND GROWTH OUTCOMES AT 12 AND 24 MONTHS OF AGE
Amanda K Crandall (1), Megan H Pesch (1), Ashley N Gearhardt (2), Allison L Miller (3), Katharine L Rosenblum (4, 5), Julie C Lumeng (1)
OBJECTIVES The current analysis sought to examine the extent to which sucking adaptations to a challenging nipple predict differences in growth at one year and two years of age. We hypothesized that infants who increased their sucking pressure, number of sucks in a feed, and mean suck duration in response to a challenging nipple would have greater weight for length z-scores (WLZ) across their first year. We further hypothesized that those who exhibited greater increases in sucking pressure, number of sucks in a feed, and suck duration in response to the challenging (vs. typical) nipple in early infancy would have a greater weight for length z-score (WLZ) across early infancy, 12 months (m) and 24m of age.
METHODS Healthy full-term infants (n=147, 51% male) were offered a bottle by their caregivers on two days, one with their typical nipple aperture size and another with a smaller nipple aperture size that made sucking more challenging. Sucking metrics (intraoral pressure, number of sucks, mean suck duration) were measured with a pressure transducer in the nipple. This task was completed at ages 2 weeks and 2, 4, 6, 9, and 12 months. A subset of infants (n=45) had anthropometric data at 24m. Multilevel modeling for longitudinal data was used to examine how sucking metric changes in response to the challenging (vs. typical) nipple were associated with WLZ concurrently at each age point across the first year. Multilevel models were also used to examine how sucking metrics in early infancy (“baseline”: 2 weeks, 2m or 4m) predicted WLZ across baseline, 12m and 24m.
RESULTS Infants who responded to the challenging nipple with greater sucking pressure had greater increase in WLZ over the first year of infancy (β = 0.0023, t(192.92) = 2.27, p = 0.024). Among infants with 24-month data, a greater increase in mean suck duration in response to a challenging nipple at baseline was associated with a greater WLZ across baseline, 12m, and 24m (β = 2.78, t(116.53) = 2.64, p = 0.009).
CONCLUSIONS This evidence suggests that a more vigorous response to a challenging nipple, even early in infancy, is predictive of greater weight for length z-scores across the first two years of life. Infants who increase their sucking pressure and mean suck duration in response to a challenging nipple may be more motivated to obtain milk than infants who maintain the same or decrease their sucking pressure and suck duration. Future research in this area should investigate the extent to which different nipple aperture sizes may be suited to different infants depending on their individual appetitive characteristics in early infancy.
46: DISPARITIES IN HIGH-RISK NEONATAL DEVELOPMENTAL CLINIC FOLLOW-UP RATES: DATABASE CREATION, PROOF OF CONCEPT, AND PRELIMINARY RESULTS
Lilia Popova(1), Emman Dabaja(2), Cambrynne Dejong(1), Sanaya Irani(1), Caroline McGowan(1), Mohammad Attar(2)
[Objectives] Our objectives were to determine how reliably prior insurance and maternal race and ethnicity were recorded in neonatal records, to assess how maternal parity affected compliance with follow-up recommendations, and to determine how multi-specialty follow-up and previous no-shows affected the odds of being lost to follow-up.
[Methods] Our cohort consisted of all patients who were born between January 1st, 2014 and December 31st, 2017, had NICU or PICU stays at Michigan Medicine within three months of life, and were referred to the high-risk neonatal developmental clinic. We generated two random samples of patients for the preliminary analysis, used manual chart review for data collection, and used SAS for data analysis.
[Results] Maternal race and ethnicity was missing from 94% of neonatal records. Insurance status during the initial admission was well-documented under “Benefits Inquiry” for 100% of patients. For each additional child, the odds of being compliant with follow-up visits in the high-risk neonatal developmental clinic were 48% lower (OR: 0.52, 95% CI: 0.30, 0.93; p=0.03), unadjusted, and 44% lower after adjusting for confounding covariates including multiple gestation and race (p=0.04). Public insurance and follow-up with three or more specialties were associated with higher odds of loss to follow-up but were not statistically significant. Patients who had at least one no-show visit had 4.8 times higher (95% CI = 1.1, 20.8) odds of being lost to follow-up (p=0.04).
[Conclusions] Self-reported maternal race and ethnicity was not consistently available in neonatal records. Families with more children and with a history of no-show visits may be at increased risk for not meeting developmental follow-up recommendations.
47: IMPACT OF THE COVID-19 PANDEMIC ON CHILDREN AND ADOLESCENTS PRESENTING TO A PSYCHIATRIC EMERGENCY DEPARTMENT
Benjamin Erjavac, Alicia Rolin, Keerthi Gondi, James Cranford, Ahmad Shobassy, Bernard Biermann, Alexander Rogers, and Victor Hong
Objectives: This study aims to further describe the effects of the COVID-19 pandemic on children and adolescent mental health by surveying individuals specifically seeking psychiatric emergency care. We hypothesized that limited access to outpatient care would be a factor in why a significant number of individuals visited the emergency department, that various age groups would experience differences in symptom predominance, and that trends in mental health symptoms impacted by the COVID-19 pandemic would evolve over the months of the study.
Methods: A mixed methods survey study was conducted on a sample of 571 children and adolescents ages 0-21 that presented to a large Midwestern academic center psychiatric emergency department between July-October 2020. The 32-question survey could be filled out by the patient or their parent/guardian. Survey data was combined with demographic data from the hospital electronic medical record. All dependent variables were categorical and were analyzed with chi-squared tests. Qualitative data was analyzed using a grounded theory approach.
Results: Among the survey respondents, there were significant increases in mental health symptoms attributed to the COVID-19 pandemic, with anxiety (71% of respondents) as the most prevalent, followed by depression (66%), suicidal thoughts or behaviors (45%), and aggression (31%). There were significant differences in reported increases in symptoms by age and gender. Additionally, 38% of participants reported that the pandemic led to a change or closure of their health care treatment, including mental health providers, with 22% reporting that the alterations in treatment access led to their emergency visit.
Conclusions: Significantly increased levels of mental health symptoms attributable to the COVID-19 pandemic were reported, with mental health impacts manifesting differently in distinct populations. Further research is indicated to assess other, more diverse populations, as well as the longer-term mental health impacts of the pandemic.
48: Physician Adherence of Otitis Media and Related Sequelae of Tympanostomy Surgeries for Pediatric Patients Admitted to the Emergency Department
Noor Sulieman, Rana Chouaib, Danny Majed, Mikaela Bradley, Mohamad Sulieman, Fatima Saad, Tami Hart-Johnson, Brandon Lucas, R. Alexander Blackwood
49: CASE REPORT: SEVERE MYCOPLASMA-INDUCED RASH AND MUCOSITIS TREATED WITH IVIG
Paris D. Rollins, BA, BSc, Andrew D. Prince, BA, Michelle Glick, MD, MA (presenting this), and Nora Biary, MD
Purpose: We present here another case of rare treatment-refractory MIRM, defined by the aforementioned diagnostic criteria. In doing so, we endeavor to expand current literature on this uncommon diagnosis and the use of IVIG treatment for resistant disease.
Methods: A literature review was completed as well as patient chart review to summarize findings, signs/symptoms, treatment, and response to treatment.
Results: The most distressing symptoms of MIRM typically resolve with supportive care and antibiotics within 1 to 2 weeks. In contrast, our patient continued to require rigorous inpatient care despite a week of antibiotics, 18 days of systemic corticosteroids, 27 days of TPN, and supportive therapy from multiple care teams. Our decision to pursue IVIG therapy was driven by anecdotal evidence that demonstrates symptom relief in refractory cases of MIRM. The proposed pathophysiology of MIRM involves aberrant activation of the apoptotic ligand Fas (CD95L), resulting in apoptosis of keratinocytes and loss of mucosal barriers.5 It has been proposed that IVIG may work by blocking this ligand receptor interaction, thus inhibiting large-scale apoptosis of epithelial cells in patients with MIRM. Working alongside pharmacy colleagues, we administered a 2 g/kg dose of IVIG over 3 days based on excellent reports of this dosing used in severe mucositis from syndromes like paraneoplastic pemphigus.
Conclusion: In sharing this case, we hope to emphasize several important aspects of MIRM management. First, early recognition based on diagnostic criteria is critical, as it is often misclassified within the spectrum of EM, SJS, and TEN. Second, treatment-resistant MIRM is a rare presentation that can be successfully treated, preferably early, with IVIG therapy, but also treated even late in the course of the disease. Third, classification of MIRM is in its infancy and it is a subject that warrants more research into its clinical presentation, histopathology, and treatment. Of note, this specific case is important as it documents a rare dermatologic case in a child of color (underrepresented in literature).
Severe Mycoplasma-Induced Rash and Mucositis Treated With IVIG (sagepub.com)
50: KEEPING CHILDREN HEALTHY AT SUMMER CAMP: A STUDY OF MEDICATIONS ADMINISTERED IN THE CAMP SETTING
Tara Funk, Leon Quach, Aditi Mahajan, Sarang Modi, Emily Supenia, Natalie Schellpfeffer, Michael Ambrose, Tracey Gaslin, Barry Garst, Andrew Hashikawa
Objective: Use data from a national camp-specific electronic health record (EHR) program to categorize all medications administered in 870 camps in 2019.
Methods: We used a deidentified data set from CampDoc.com, an online EHR that allows parents and nurses to input campers’ medications. Medications were classified based on drug type, mechanism and indication following a coding book developed with a pediatric pharmacist (Table 1). Data on all available campers between the ages of five to seventeen years were analyzed using descriptive statistics.
Results: Data were available from 75,072 campers encompassing 163,853 medications from 870 camps, with camps represented from all U.S. census geographic regions including: Northeast (31%), Midwest (23%), South (24%), and West (21%).
Medications were classified into 26 primary classifications (Table 2). Within the primary classifications, Antihistamines/Allergy Agents represented the highest proportion of medications at 24.14% (n = 39,560), followed by Psychotropic Agents at 20.46% (n = 33,521), Emergency and Rescue 115 Agents at 12.05% (n = 19,740), Herbal, Supplement and Vitamin at 7.22% (n = 11,838), and Respiratory at 5.33% (n = 8,735). These five categories comprised nearly 70% of all camp medications.
In total, 98,268 medications were further organized into 52 distinct medication subcategories (Table 2). Notable medication subcategories included the following: Attention Deficit Hyperactivity Disorder Agents (11.37%; n = 18,634), Asthma Rescue (7.85%; n = 12,860), Anaphylaxis Rescue (3.80%; n = 6,234), Status Epilepticus Rescue Agents (0.31%; n = 506), and Prescription Pain Medications (0.51%; n = 836). There were also a substantial number of medications for mental health: Anti- Depressants (3.35%; n = 5,481), Anxiolytics (3.29%; n = 5,394), Anti-psychotics (1.41%; n = 2,314), and Bipolar Agents (0.17%; n = 283).
Conclusions: Our study is the first to describe the vast quantity and wide spectrum of medications used by campers nationally. Our data illustrate the immense effort required by camp healthcare staff to receive, store, dispense, and triage medications to ensure campers’ needs are met for routine health care and emergencies. Pediatricians should advocate for robust safety and quality improvement measures to provide appropriate safeguards against adverse medication events to optimize campers’ health and safety while attending camp.
51: PREDICTORS OF SEVERE SEPSIS IN PEDIATRIC INTESTINAL FAILURE (POSSIPIF) - RESEARCH IN PROGRESS
Helen Mulcahy, Alex Rogers
Objectives The POSSIPIF study was designed to test the hypothesis that there are objective factors that confer risk for poor outcomes in febrile intestinal failure patients. The first poor outcome is severe sepsis. The second poor outcome is patient death. The factors studied include age, race, type of CVL, initial vital signs, height of fever, subjectivity of fever, laboratory values (inflammatory markers, bilirubin, coagulation factors, glucose), blood culture results, urine culture results, antibiotics administered. The poor outcome of severe sepsis was measured based on need for intensive care unit admission, evidence of hypotension for age, bacteremia, lactic acid peaks, creatinine peaks, need for vasoactive support. The poor outcome of death was measured by patient death while admitted or within 30 days of discharge.
Methods A multi-center, retrospective study was conducted. Data was collected separately from each site’s electronic health record (EHR). Qualifying patient emergency department encounters were chosen for review within a five year date range (2014-2019). Patient encounters were included based on pediatric age, qualifying diagnosis of intestinal failure or enrollment in the intestinal failure program, presence of central venous line and presence of fever at home or in the emergency department (ED). Patients were excluded if they were transferred from an outside facility, had a history of solid organ transplant or had received parenteral antibiotics before the ED encounter. Data is being collected and inputted.
Results Results are not available as this study is ongoing across many sites. The results will hopefully provide odds ratios for predicting severe sepsis for the variables analyzed such as demographics, type of CVL in place, vital signs, antibiotic therapy. It will also predict mortality as a secondary outcome.
Conclusion Conclusions are not available as this study is ongoing across many sites. The conclusion will hopefully provide a summary findings and how to apply them clinically. This conclusion will hopefully fill an evidence gap.
65: CAREGIVERS’ PERCEPTION OF UNIVERSAL TRAUMA SCREENING IN PEDIATRIC MEDICAL SETTINGS
Yi Tak (Daisy) Tsang, Cassie N. Ross, Katherine L. Rosenblum, Kristin A. Kullgren
Objectives: The goal of the study is to assess parents’/caregivers’ acceptability, preference, and perceived utility of universal trauma screening in pediatric settings. This study also aims to highlight potentially differing perspectives from ethnic minority subgroups.
Design/Method: Caregivers of children with chronic illnesses were asked to rate their comfort level, perceived benefits and detriments, and preferences about trauma screening via a nationwide online survey. Caregivers were recruited through pediatric illness foundations, parent support groups, general social media advertisements, and the “UM Health Research” platform.
Results: Data collection is completed with 1236 responses received. Incomplete or fraudulent responses are being screened out. Data cleaning and analysis are in progress.
Conclusions: This study will lay critical groundwork for the implementation of trauma screening, which is an essential building block as the field continues to develop effective, person-centered, and culturally-sensitive trauma-informed care practices among pediatric healthcare settings.
Research supported by department intramural funding – Fall 2021 Department of Pediatrics Resident and Fellow Research Grant Program (Percy J Murphy, MD and Mary C Murphy, RN Endowed Children’s Research Fund)
57: Adolescent and Young Adult Opinions on Transgender Athletes in Sports
Waselewski, Alexander C1; Kruger, Laura G2; Waselewski, Eric A3; Waselewski, Marika E2; Chang, Tammy2
58: Variations in Prevalence of Newborn Drug Testing by Birth Parent Race and Ethnicity at Michigan Medicine
Melissa Plegue1,2, Sebastian Schoneich2, Tori Waidley3, Justine Wu2, Lauren Oshman2, P Paul Chandanabhumma2, Christopher Frank2
Methods: Electronic Health Records were extracted for dyads of newborns and birth parents who received at least one prenatal care visit and delivered at MM between July 2014 and December 2020. Birth parent sociodemographics, delivery- and prenatal-related diagnosis codes, procedures and prenatal urine drug screening (UDS) data were analyzed. Associations between NDT and demographics, presence of specific diagnoses, prenatal UDS orders and results and delivery year were assessed using logistic regression with generalized estimating equations to account for individuals with multiple births in the study period.
Results: We identified a total of 26,366 deliveries across 21,648 birth parents that met study criteria. NDTs were ordered for 1,237 (4.7%) of these deliveries. Across all years, NDT ordering was significantly higher for newborns of Non-Hispanic (NH) Black birth parents (11.3%) compared to newborns of birth parents of all other races (4.2% NH White, 0.2% Asian, 3.5% Hispanic and 4.8% Other Race, p<0.001). Drug testing was more likely to be performed on newborns of birth parents with positive prenatal UDS (73.8%) than newborns of birth parents with negative prenatal UDS (31.3%) or birth parents who did not undergo prenatal UDS (2.4%) (2.4%) (p-values<0.001). This finding was not consistent across races; newborns of Black birth parents were more likely to undergo drug testing even when the birth parent had not undergone UDS during pregnancy (7.3%) compared with newborns of all other races (1.9% NH White, 1.8% Hispanic, 0.7% NH Other including Asian).
Conclusions: Newborns of Black birth parents were more likely to undergo drug testing than newborns of non-Black birth parents, irrespective of risk factors. Findings suggest racial bias in NDT and underscore the need for formal institutional guidelines to promote equitable practices in newborn drug testing.
59: ASSESSING THE IMPACT OF COVID-19 ON IMMUNIZATIONS IN MICHIGAN
Hannah K. Peng1, Ryan Malosh2, Sukhesh Sudan2, Hannah Forsythe2, Abhinav Nalla2, Pooja Patel1, Kevin J. Dombkowski1
Objective: The objective of the COVID-19 Impact Report is to monitor the potential influence of the COVID-19 pandemic on non-COVID immunizations reported to the Michigan Care Improvement Registry (MCIR).
Methods: MCIR was queried to assess trends in doses administered over time (2018-2021) and population-level immunization coverage. The Advisory Committee on Immunization Practices (ACIP)-recommended vaccine series coverage was assessed for children aged 19-35 months and for adolescents aged 13-17 years. Non-influenza/non-COVID doses administered were quantified by insurance eligibility (Medicaid enrollee vs. not), age group, vaccine type, and facility type.
Results: Between March 2020 and December 2021, immunization series coverage decreased by 4.4 percentage points for children aged 19-35 months, and 3.8 percentage points for adolescents aged 13-17 years. The pandemic exacerbated an existing disparity in series coverage by Medicaid status, with Medicaid-enrolled children 19-35 months of age having coverage 10.2 percentage points lower than those without Medicaid as of December 2021. The number of non-influenza/non-COVID immunization doses administered in January-December 2021 was 8.2% lower for children 0-8 years of age and 15.2% lower for adolescents 9-18 years of age, compared to the January-December 2018-2019 average. However, this was an improvement over the decreases in administrations seen in 2020, which were 10.8% lower for children and 23.4% lower for adolescents, compared to the January-December 2018-2019 average. While most childhood vaccines saw a consistent increase in administrations following 2020, Polio and Hib failed to rebound to pre-pandemic levels until the last quarter of 2021. For adolescents, Hepatitis A coverage failed to rebound throughout 2021. As of December 2021, vaccine administrations to children and adolescents were similar to pre-pandemic levels at pediatric and family practice sites, but still lagged pre-pandemic levels at local health departments.
Conclusions: Widespread decreases in immunizations were observed throughout Michigan following the onset of the pandemic. While immunization rates are starting to improve, they have not yet reached pre-pandemic levels. Statewide immunization registries such as MCIR are an important tool to evaluate the impacts of the pandemic on immunization delivery and identify potential opportunities for improvement.
60: CYSTIC FIBROSIS RELATED DIABETES – ADHERENCE TO SCREENING AT A LARGE CLINICAL CENTER
Nellie Said, Jung Eun Lee, Emily Dhadphale, Joyce Lee, Samya Nasr
Results At Michigan Medicine, among all patients eligible for screening with an OGTT, there was a center-level rate of ordering OGTT’s of 16.5%, and a rate of screening with completed OGTT’s of 13.8 %. 83% OGTT’s ordered were completed by patients, while 100% of HbA1c’s ordered were completed. Of the OGTT’s completed, 24% screened positive for pre-diabetes and 3.4% screened positive for diabetes. Of the HbA1c performed, 31% screened positive for pre-diabetes, and 1.2% screened positive for diabetes. There were significant differences by age in rates of screening (p<0.01) and rates of completion (p<0.01) with higher rates of screening in younger vs older patients, but not by gender or race (Table 1).
Conclusions Overall, rates of adherence to OGTT ordering and completion were suboptimal. Patients had a higher rate of adherence to diabetes screening with HbA1c compared to OGTT and ordering adherence was higher for pediatric vs adult patients. While current CFF guidelines recommend the OGTT as the standard of screening for CFRD, OGTT testing is more burdensome, and takes more time to complete among a patient population that already has high healthcare utilization. Continued analysis of our data is needed to further determine outcomes of screening, specifically trends in BMI, pulmonary function tests (FEV-1 and FEF25-75), number of hospitalizations and variations in insulin use.
61: Hydroxyurea Utilization Patterns Among People Living with Sickle Cell Disease
M. Rushing1, S. Horiuchi2, M. Kayle3, S. Reeves1, S. Paulukonis2
Objectives: Identify hydroxyurea utilization patterns among Californians living with SCD who receive Medicaid benefits.
Design/Method: The analysis was completed using the California Sickle Cell Data Collection (SCDC) program data. The SCDC is a CDC funded public health surveillance at the population level. Californians living with SCD enrolled in Medicaid with at least one filled hydroxyurea prescription between 2010-2018 were included in the analysis. The observation period for each participant began following the first filled hydroxyurea prescription between 2010 and 2017 and ended 365 days later. The medication possession ratio (MPR) was used as a proxy measure of utilization. The monthly MPR was calculated by summing the total number of days of filled hydroxyurea prescriptions divided by the total number of days in the month, while accounting for days admitted inpatient. Group based trajectory modeling was used to identify distinct MPR trajectory groups. Model selection was based on BIC, significance of group membership, and clinical relevance. A chi-squared test was conducted to determine the association between age and trajectory group membership.
Results: There were 713 Medicaid enrollees with SCD included in the analysis: 57% were under 21 years old and 50% were males. Three distinct groups of hydroxyurea possession patterns were identified: persistently high (n=263, 37%), moderate decreasing to low utilization (n=253, 35%), and low decreasing to no utilization (n=197, 28%). The distribution across the three groups were similar between sexes. The association between age and trajectory group membership was significant (χ2=23.56, p<.01). Among the pediatric population, 44% had persistently high hydroxyurea utilization (n=178) and 22% had low decreasing to no utilization (n=89). In contrast, among adults, 28% had persistently high hydroxyurea utilization (n=85) and 36% had low dropping to no compliance (n=108).
Conclusions: Despite the evidence of hydroxyurea in reducing pain crises, the majority of people with SCD that filled hydroxyurea prescriptions did not remain adherent. A more adherent utilization pattern was observed among the pediatric population, suggesting there are specific factors among the pediatric population promoting higher adherence that are not present among adults. Interventions are urgently needed to increase adherence to hydroxyurea among people with sickle cell disease.
62: DISPARITIES IN HEIGHT AT THE TIME OF INFLAMMATORY BOWEL DISEASE DIAGNOSIS
Joann M. Samalik1, Jeremy Adler1,2
Objectives We aimed to determine if patients with lower socioeconomic status are disproportionately shorter at time of diagnosis.
Methods This is a retrospective evaluation of prospectively collected data from patients with IBD in the ImproveCareNow (ICN) Network (2007-2018). Patients in the ICN registry were included if enrolled <3 months from IBD diagnosis; excluded if age >18 yr, or missing height at diagnosis. Our primary outcome was height Z-score at diagnosis. Height Z-score <-1 was considered short, and <-2 very short. Insurance at ICN enrollment was categorized as private insurance or no private insurance, regardless of Medicaid or supplemental insurance. Bivariate comparisons were made using Student’s t-test, and chi-squared analyses. Multivariate logistic regression used patient and disease characteristics, race, ethnicity, gender, and insurance status to predict short or very short stature as independent variables. The Institutional Review Board granted a waiver of consent.
Results Among the 2867 patients included, 1268 were female (44%), median age 14.2yr (interquartile range 11.3-16.2). Diagnoses were 62% Crohn’s disease, 30% ulcerative colitis, and 8% IBD unclassified. Demographics: 278 (12%) Black, 1,866 (80%) White, 186 (8%) other race, 150 (5%) Hispanic, and 2141 (75%) non-Hispanic (20% ethnicity missing). Insurance: 2015 (70%) private insurance, 610 (21%) no private insurance, (8% missing).
More patients without private insurance (26%) were short at enrollment than those with private insurance (18%; 0<0.001; Figure 1). There were no differences in short stature by race (p=0.37). However, 27% of Hispanic patients were short, compared to 20% non-Hispanic (p=0.03). There was an interaction between ethnicity and insurance, where more Hispanic patients without private insurance were short (31%) compared to all other groups (p=0.007).
Conclusions Patients without private insurance are more likely to be short at IBD diagnosis than those with private insurance. There is no plausible biological explanation for differences in height by insurance status. This difference may relate to diagnostic delay and duration of untreated disease. However, food insecurity may also contribute. Qualitative studies are needed. Efforts are needed to minimize diagnostic delay and address food insecurity among low-income families.
Figure 1. Incidence of Short Stature at diagnosis of inflammatory bowel disease by insurance type
63: ACUTE HEALTHCARE UTILIZATION FOR INDIVIDUALS WITH SICKLE CELL DISEASE IN MICHIGAN
Pooja N Patel1, Krista Latta1, Hannah K Peng1, Kevin J Dombkowski1, Sarah L Reeves1
64: THERAPY AND MEDICAL APPOINTMENT UTILIZATION AMONG MEDICAL STUDENTS
Keats Ewing and Sarah Thilges
Objective: Despite these well-studied trends, more work is needed in the utilization of mental health resources by medical students.
Design/Methods: The authors measured outpatient mental health resource (OMHR) utilization trends among medical students by administering a questionnaire to students at one medical school in December 2020. The primary outcome measure was defined as the use of outpatient mental health services with subgroup analyses of preclinical versus clinical years of medical school and comparison to utilization of other medical appointments.
Results: Of 699 medical students available for participation, 27.9% (n = 193) completed the questionnaire, 49% (n = 94) stated they had utilized OMHR at some point during their time in medical school. Of those, 57% (n = 50) reported canceling their OMHR appointments due to mandatory medical school requirements and 79% (n = 70) avoided making OMHR appointments. In comparison, 80% (n = 148) attended a medical appointment after starting medical school while 57% (n = 83) had to cancel their medical appointments and 80% (n = 119) avoided making medical appointments. In our subgroup analysis, there was no significant difference in OMHR utilization between students in preclinical versus clinical years, but those in their clinical years were significantly more likely to cancel their OMHR appointment than those in preclinical years. There was not a significant difference in canceling medical appointments during preclinical versus clinical years. Women were significantly more likely to attend OMHR appointments than men, but there was no significant difference between men and women in attending medical appointments.
Conclusion: The authors’ findings support the need for further medical school administrative support of students as they attempt to receive the mental health and medical care they deserve.
66: EXPERIENCE OF STIGMA AND ITS RELATIONSHIP TO IDENTIFICATION WITH THE NEURODIVERSITY MODEL FOR INDIAN PARENTS OF CHILDREN WITH AUTISM SPECTRUM DISORDER
Sahita Manda1, Elizabeth Buvinger2, Shichi Dhar3, Harika Veldanda4
Objectives: In collaboration with the University of Michigan Department of Psychology and the national Indian organization Action For Autism, our research aims to understand the experience of stigma and its relationship to identification with the neurodiversity model for Indian parents of children with ASD. The neurodiversity model proposes that ASD is a natural variation of human behavior that should be celebrated (Jaarsma & Welin, 2011). This study explores the extent to which Asian value adherence, child functioning, and perceived ASD stigma contribute to parental alignment with the neurodiversity model. It also investigates the ways in which alignment with the model affects parental stress, isolation from family and friends, parenting goals, identification of child’s strengths, and positive perceptions about raising a child with ASD.
Method: The study was carried out by administering anonymous online surveys through the platform of Qualtrics to Indian parents residing in India (N=82; full data n=56) with children aged 17 or younger diagnosed with ASD.
Results: Statistically significant correlations between a child’s ASD behaviors, perceived ASD stigma, parental stress, and isolation from family and friends were found. Neurodiversity alignment was also identified as a mediator in the relationship between perceived ASD stigma and parental stress.
Conclusion: Findings demonstrate that perceived stigma from ASD-related behaviors can compel parents to isolate themselves from family and friends to avoid possible rejection or exclusion. Results also support the idea that social surroundings, of which stigma is a part, must be conducive for parents to adopt a strength-based approach. More complex mediation analyses incorporating the neurodiversity alignment variable as well as Asian value adherence will be conducted and will have implications for the adoption of strength-based practices and the reduction of stigma associated with ASD within different cultural contexts.
67: HOSPITALIZATION AND MORTALITY DUE TO COVID-19 AMONG PEOPLE BORN 1987-2019 WITH SICKLE CELL DISEASE OR SICKLE CELL TRAIT IN MICHIGAN
Krista Latta1, Susan Paulukonis2, Isabel Hurden3, Sarah Reeves1
Objective: Assess COVID-19 related hospitalization and mortality among those living with SCD or trait using population-based cohorts in the state of Michigan.
Methods: We linked all COVID-19 infections in the Michigan Disease Surveillance System from March 2020-November 2021 to births in newborn screening records (NBS) from 1987-2019 in the state of Michigan. Individuals that did not link, had an unknown NBS hemoglobin result, or had an abnormal, non-sickle cell hemoglobinopathy were excluded from analysis. Race, sex, and age were obtained from NBS; COVID-19 hospitalization and mortality were obtained from the Michigan Disease Surveillance System. We used logistic regression models with generalized estimating equations (GEE) to assess the relationship between hemoglobin status (normal hemoglobin, SCD, trait), COVID-19 hospitalization, and COVID-19 mortality. GEE was used to account for individuals with multiple infections. We limited models to those identified as Black race due to missing race data concerns across all hemoglobin groups. Models were adjusted for sex and age.
Results: We linked 329,552 infections among individuals ages 0 to 33 from the COVID-19 registry to NBS records (98.7% normal hemoglobin, 0.1% SCD, 1.2% trait). Of those that linked, 14.0% (n=45,630) were identified as Black race. For those identified as Black race, the adjusted odds of hospitalization for SCD was 15.4 (95% CI: 10.4, 22.9) times greater than the normal hemoglobin group. The adjusted odds of death due to COVID-19 in those with SCD was 15.9 (95% CI: 4.8, 52.5) times greater than the normal hemoglobin group. We did not find a significant difference in odds of hospitalization or death between the trait and normal hemoglobin groups.
Conclusions: Individuals with SCD are at a higher risk of severe COVID-19 outcomes compared to individuals with normal hemoglobin; however, trait does not appear to be a significant risk factor. These results demonstrate that vaccinations and access to early COVID-19 treatments are important to promote among populations living with SCD.
68: MULTICENTER EVALUATION OF PATTERNS OF AND REASONS FOR BIOLOGIC DISCONTINUATION AMONG CHILDREN WITH CROHN’S DISEASE
Jana Creps1, Dianne C Singer2, Michaella K Baker2, Sabina Ali3, Jess L Kaplan4, Jonathan Moses5, Brad A Pasternak6, Charles M Samson7, David L Suskind8, Jeremy Adler2,9
Objectives To determine how often children with CD discontinue biologics, the reasons for, and evaluations performed prior to discontinuation.
Methods Clinician and patient parents were involved in creating and conducting this study. We identified all patients with CD at 6 Pediatric Inflammatory Bowel Disease Centers in the US (2010-2021) from the ImproveCareNow (ICN) Network registry. Inclusion criteria required enrollment in ICN within 30 days of diagnosis and age at diagnosis <18 yr. Biologics included infliximab, adalimumab, certolizumab pegol, ustekinumab, vedolizumab, and their available biosimilars. Medical record abstraction supplemented the prospectively collected ICN registry data. Patient characteristics and treatment patterns, evaluations prior to biologic discontinuation, and reasons for discontinuation were classified. Changes in biologics were visualized with Alluvial plots. Bivariate comparisons were performed using Student t-test and chi-square with Stata 17.0. The study was approved by each institution’s Institutional Review Board.
Results To date, data from 358 of 1,009 (35%) patients were analyzed. In total, 305 (85%) started at least one biologic. Of those, 132 (44%) switched to a 2nd biologic (including 45 who switched to a biosimilar). Of all biologic starters, 31 (9%) went on to a 3rd or 4th biologic during pediatric care. Reasons for biologic discontinuation included primary non-response (8%), secondary loss of response (23%), developing anti-drug antibodies (6%), adverse event (18%; 3 considered serious), non-adherence or choice (6%), and insurance problems (15%). Among all who discontinued their 1st biologic for inadequate efficacy, 90% underwent at least some pre-discontinuation evaluation, including checking serum level (81%), fecal calprotectin (21%), endoscopy (36%), or MR/CT imaging (55%).
Conclusions In this multicenter study of pediatric CD, we found 44% of those who started their 1st biologic eventually discontinued it. Ultimately nearly 10% discontinued 3 or more biologics. Medical reasons dominated, but 15% of patients discontinued due to insurance problems. Strategies are needed to reduce the rate of biologic discontinuation to improve outcomes and preserve long-term treatment options.
Figure 1. Alluvial plot of changes in medication use. Those who never changed remain in the same category.
69: Use of Recommended Antiviral Medications for Children Hospitalized with Influenza 2010-2020
Kavita Warrier1, Harlan McCaffery2, Richard Eikstadt2, Sarah Reeves3, Emily Martin4, Alison Tribble1
52: ADULT VERSUS PEDIATRIC CARE SETTING DIFFERENCES IN ‘REASON FOR ETHICS CONSULT’ FOR PATIENTS 18 TO 26 YEARS OLD
Janice Firn, Samantha Lyons, George Freigeh, Kelly Matula
Objectives We hypothesized that there would be differences between ethics consultation requests and primary contextual features based on the setting (adult vs. pediatric) where the consult originated.
Design/Method We conducted a retrospective review of 613 ethics consultation notes to identify patients 18-26 years old seen by either the Adult or Pediatric Ethics Committees at Michigan Medicine from 1/1/2016 - 12/31/2020 (HUM00197110). We collected demographic information and coded consultation notes using a classification schema for ethics consultation adapted from Nilson et al. and Johnson et al. and analyzed these using descriptive statistics.
Results Forty-six notes (14 pediatric, 32 adult) were identified; 43 of which were unique patients. The median age was 24 in the adult setting and 19 in the pediatric setting. All patients spoke English with 50% female; 96% were non-Hispanic, 65% were White, and 78% were inpatient. The primary ethical issue in the adult setting was refusal of recommended treatment (17%), while the principal contextual issue was communication disputes between the staff and the patient (12%). The leading ethical issue for the pediatric setting was goals of care (11%), and the dominant contextual issue was tied (8%) between communication conflicts between the staff and family and quality of life.
Conclusion The ethical dilemmas and related contextual features experienced by this population are different based on setting. Regardless of setting, improved patient-provider communication may ameliorate some of these challenges, and certain demographics (age, race, language, inpatient) from this study raise concerns for utilization of ethics services for some patients. Further education on communication, implicit bias, and ethics services may be needed.
53: Perspectives of Language Barriers and Interpretive Services Use in the Neonatal Intensive Care Unit Among House Officers and Clinicians
Aunum Akhter, Michael Redmond, Kate Stanley
Objective: We aimed to assess the knowledge, skills, and attitudes of current neonatology fellows and early career neonatologist regarding language barriers among LEP families and best practices using interpretive services (IS) in the NICU.
Methods: An anonymous needs assessment was created using Michigan Medicine’s Qualtrics software. It consisted of 32 questions grouped into demographic, knowledge, confidence, and attitude sections. Specific scores were created for each section and then compared across various demographics. The needs assessment was distributed electronically using the American Academy of Pediatrics (AAP) Training and Early Career Neonatologists (TECaN) listserv to neonatology house officers and early career neonatologists. Aggregated data was analyzed using descriptive statistics and comparative analysis.
Results: One hundred and nineteen questionnaires were completed and analyzed. Most respondents were female, Caucasian, and native English speakers who did not speak a second language. Neonatology fellows accounted for 49% of respondents with even representation across all three years of fellowship. Fifty-one percent of respondents were early career neonatologists with an even distribution of clinicians who graduated one to seven years from fellowship. Most respondents (88%) frequently used phone and video IS. However, 87% of respondents preferred in-person IS. While respondents almost always used IS when obtaining consent or breaking bad news, only 28% of respondents used IS half the time or less when providing families with daily patient updates. Mean confidence scores in using IS across different clinical encounters were significantly higher among respondents who received post-graduate education about IS (p=0.04) and specific training on cultural norms/sensitivities of ethnic minorities (p=0.004) compared to those who did not receive education.
Conclusion: Training in cultural sensitivity and IS skills that specifically addresses daily patient communication for LEP families are two areas to target when designing a health disparities educational curriculum for neonatology medical learners.
54: Pediatric Continuous Renal Replacement Therapy Curriculum for Pediatric Critical Care Medicine Fellows
Brooke Blazius, Rebecca Lombel, Debbie Gipson, Vivian Shih, Deborah Rooney
Objectives: Our institution has twice yearly one-hour long lectures in pediatric Continuous Renal Replacement Therapy (CRRT) management for the Pediatric Critical Care Medicine (PCCM) fellows. We developed a formalized, virtual pediatric CRRT curriculum to train PCCM fellows on indications to start and stop pediatric CRRT, prescription writing, electrolyte management, nutrition management, and CRRT machine review. The aim was to improve cognitive and confidence skills in pediatric CRRT management in the PCCM fellows.
Methods: A general needs assessment was distributed to the PCCM fellows, CRRT nurse initiators, and PICU attending physicians. Three modules were created to teach pediatric CRRT prescription writing, management of pediatric patients on CRRT, and CRRT machine navigation. The format of educational modules was recorded videos on a virtual learning platform. This allowed PCCM fellows to complete the educational content at their own pace. The PCCM fellow completed pre- and post-module assessments to measure for cognitive and confidence improvements, and a final anonymous evaluation of the curriculum was administered.
Results: Seven of nine PCCM fellows completed the curriculum. There was a statistically significant improvement in pre- and post-module scores, with p-value less than 0.05 for Modules 1 and 3, and Cohen’s d of 2.00 and 1.07, respectively. There was statistically significant improvement in confidence for all three modules, Cohen’s d ranging from 0.49 to 1.16. All fellows that completed the curriculum recommended it be offered to trainees in subsequent years.
Conclusion: This curriculum resulted in improved confidence and knowledge in pediatric CRRT management. In facing barriers with limited in person interaction due to the COVID-19 pandemic, a flexible virtual curriculum has been shown to be successful. Next steps include application of the curriculum to other centers that perform pediatric CRRT and development of in-person simulation cases to enhance the educational experience.
55: DEVELOPING A SUMMER CAMP TO EXPOSE YOUTH IN UNDER-RESOURCED AREAS TO PSYCHOLOGY
Haggerty, D. 1, Birnbaum, R. 1, Bourchtein, E. 1, & Harris, S. D.1
56: Evaluation of Gender Bias in Pediatric Faculty Assessments by Residents at a Tertiary Care Children’s Hospital
Alexandra Blumer, Rebekah Shaw, Katrina Foo, Leah Rappaport
70: ED Boarding: Inpatient Provider Perception of Safety Concerns and Gaps in Knowledge of Policies
Jessica Hoffman, Blair Lenhan, Kyle Yoo, Shoshana Rudin, Genevieve Allen, Maria Pliakas, Samiksha Tarun PI’s: Emily Jacobson, Julie Barrett
METHODS: This project was done as part of the ED Boarding Initiative through the House Officer Quality and Safety Committee (HOQSC). We first met with leadership in AES (Adult Emergency Services) and CES (Children’s Emergency Services) in 2019-2020 to better understand current policies and procedures with regards to ED boarding. We also reviewed house officer and nursing safety reports. We surveyed all house officers in March 2020 on perceived safety concerns with the care provided to boarding patients compared to non-boarding patients. We attempted chart review to identify potential delays in care but ultimately chose to defer further analyses given the complexities and changes because of the COVID-19 pandemic. We performed focus groups with nurses in both CES (2021) and AES (2021-2022), along with a “go and see” with an AES nurse (2021), to better understand the nursing perspective. We then performed root cause analyses through which we highlighted communication barriers between nursing and inpatient providers along with a lack of inpatient provider knowledge of boarding procedures, which we assessed further through surveys sent in January 2022 to Internal Medicine/Med-Peds house officers and MFH providers.
RESULTS: On the initial survey sent to all house officers in March 2020, we had 171 responses and the vast majority (>85%) felt that the care provided to boarding patients is less safe than the care provided to non-boarding patients, with the most common reported issues being the release and completion of orders, communication with nursing, physical distance, and perceived delays in care. Focus groups with AES and CES nursing revealed similar concerns, along with particular concern with inpatient providers releasing orders which is against current policy. We surveyed 112 Internal Medicine/Med-Peds house officers (63%) and MFH providers (37%) on practices for placing and releasing orders for patients who are boarding in the ED, which revealed that 93% have incorrectly released orders themselves, 68% currently place orders in the incorrect location in Michart when patients are boarding, and 88% are not aware of a protocol for how orders are supposed to be placed and released when patients are boarding.
CONCLUSION: The work of this study has been primarily focused on describing the current state of ED boarding, which has changed and become even more complex during this project a result of the COVID-19 pandemic. We have shown that many inpatient providers have concerns with the safety of patients who are boarding in the ED. There are many challenges and areas for improvement in communication, the process of boarding procedures, and education to providers. We provided a brief education intervention to Internal Medicine/Med-Peds house officers and MFH providers in February-March 2022 to inform them of current protocols with regards to releasing orders along with suggested communication strategies to improve teamwork with AES nursing. We plan to assess the effectiveness of this intervention, distribute this education to other specialties, and continue working on additional interventions for quality improvement.
71: IMPROVING CONTINUITY IN RESIDENT PRIMARY CARE CLINIC: RESIDENT AS PCP TRIAL
S. DiBattista1; G. Freigeh1; L. Helms1
Purpose: The purpose of our study was to establish a pilot program identifying Pediatric residents as the PCP to assess impact on continuity. We hypothesized that residents listed as PCP would increase continuity compared to those not listed as PCP.
Methods: This study was conducted over an 18-month period. A cross-sectional analysis of EHR data was performed on patient visits between July 1, 2020 - December 31, 2021 at two continuity clinic sites from 4 residents identified as PCPs and compared to 20 peers (non-PCPs). Survey data was also collected from resident PCPs and supporting faculty during this time. The primary outcome was the percent of patients seen at least twice. A two-tailed t-test compared the percentage between the resident PCPs to non-PCPs from this time period and to all Pediatric residents from the prior data set. Percent of patients seen at least twice by all Pediatric residents during the two time periods was also compared using two-tailed t-test. Survey data was reviewed for trends and subjective comments; no statistical analysis was completed given small sample.
Results: The percent of patients seen at least twice did not differ significantly between groups. Resident PCPs saw 7.4% of patients at least twice compared with 4.5% for non-PCPs (p=0.14). Overall percent of return visit patients decreased from 6% to 5% (p=0.10). Based on survey data, resident PCPs increased their patient panel to 5-20 patients by 18 months. They reported answering inbasket messages rarely to a few times per month. Resident PCP autonomy and clinic satisfaction slightly to greatly increased at 18 months. Faculty reported their time managing inbasket messages was unchanged to slightly decreased, with no faculty concerns or significant issues noted.
Conclusion: Our data show a trend toward greater continuity among resident PCPs. It also shows greater satisfaction among resident PCPs without changing overall work burden. There were several limitations to our study. The trial group included a small number of residents and represented those likely motivated to take on an increased role in continuity clinic. The COVID-19 pandemic also impacted the study period. We hope this data can encourage residents and program administration to augment the continuity clinic experience.
72: ADDRESSING THE TIME TO INITIATION OF PHOTOTHERAPY IN THE NEWBORN NURSERY
Matthew Wolf, Elise Gross, Emily Jacobson, Mayya Malakh
Objectives: This project aimed to reduce the time from order to initiation of phototherapy by 25% in order to subsequently reduce the length of stay of jaundiced infants. Secondary outcomes included an effort to reduce the number of total blood draws while under phototherapy as well as the percent of first re-checks under 6 hours from initiation.
Design/method: A “Phototherapy Quick Tips” information card was generated and placed in the resident workroom on the newborn floor for use. This card outlined the need for a serum bilirubin level based on recent Northern California Neonatal Consortium guidelines. This card also provided instructions to help residents time their subsequent serum bilirubin levels appropriately, based on the time of initiation of phototherapy. Lastly, an automatic page was incorporated into the phototherapy order set to alert nursing of the placed order, so as to eliminate potential delays in communication between members of the care team regarding this order. Data was collected via retrospective chart review for three months prior to and three months after implementation of these interventions. Analysis was performed using independent two-sample t-test and two proportion z-test.
Results: Time from order to initiation of phototherapy, overall length of stay, and percentage of first bilirubin re-checks less than six hours from starting phototherapy remained unchanged despite implementation of interventions. However, the number of bilirubin lab draws while undergoing phototherapy did reduce with statistical significance.
Conclusions: While the primary objective of reduction time time from order to initiation of phototherapy was not achieved, the number of lab draws while under phototherapy was reduced. However, the clinical significant of this reduction is arguable. Overall, there remains numerous intervention points to help reach the goal of a 25% reduction in time from order to initiation of phototherapy.
73: IMPLEMENTATION OF A COMMUNITY PARTNERSHIP ADVOCACY CURRICULUM
E. Hovel1; S. DiBattista1; M. Naughton1; J. Sturza2
Methods: This is an ongoing prospective pre- and post-intervention study of a new community-based advocacy curriculum for pediatric residents (N= 31) at a large academic children’s hospital. Our curriculum began with self-directed exploration of an online bank of resources relating to local youth justice reform, legislative advocacy, social media advocacy, and writing Op-eds. Residents then worked with a local nonprofit organization to learn about the youth justice system and exercise concrete advocacy skills. We distributed an anonymous survey to residents before and after their participation in the curriculum. The survey assessed comfort in advocacy-related skills and attitudes towards advocacy using Likert-type 5-point scales. To analyze the data, paired t-tests or McNemar tests were used to assess change.
Results: Comfort in various areas was assessed on a scale from 1 (extremely uncomfortable) to 5 (extremely comfortable). Comfort in working with community organizations increased from an average of 3 to 3.8 (p = 0.0004). Comfort in exercising legislative advocacy, social media advocacy, and writing Op-eds all increased significantly (2.5 vs 3.5, 1.9 vs 3, and 2.3 vs 3.7 respectively, p <0.0001). Residents’ perceived importance in highlighting disparities while advocating for children increased, though the change was not significant (p = 0.06). Perceived awareness of local youth justice reform more than doubled on a 5-point scale (1.5 to 3.3, p <0.0001). Lack of knowledge as a barrier to advocacy decreased from 53% to 10% (p = 0.0005), but lack of time remained a barrier (73% vs 87%).
Discussion: This curriculum was easily nested into an existing community health rotation month, which is required by the ACGME for pediatric residency programs. After participating in this curriculum, residents’ comfort with advocacy in general, working with community organizations, and exercising the three skills our curriculum focused on all increased to a statistically significant degree. Additionally, far fewer residents cited lack of knowledge on how to advocate as a barrier to advocacy. As this is an ongoing pilot, our sample size was small at the time of statistical analysis. It will be important to continue analysis with a larger sample size, and to integrate resident feedback in improving this curriculum.
74: EXAMINING FOLLOW-UP CARE FOR CHILDREN AT-RISK OF DEVELOPMENTAL DELAY TO REDUCE HEALTH DISPARITIES
Sharnita D. Harris, Teryn Bruni, Jennifer Radesky, Layla Mohammed, Danielle Haggerty, Tiffany Munzer, Elizabeth Koval
Objective The aim of this project was to better understand barriers in developmental follow-up care by assessing current provider responses to abnormal development screeners, provider and caregiver acceptability of those responses, and subsequent engagement with follow-up resources.
Design/Methods Mixed methods, multi-informant interviews were used to evaluate developmental services at an underserved primary care clinic affiliated with an academic institution. Of 111 eligible participants (aged 4 to 60 months, determined at-risk for developmental delay during a health maintenance appointment between Aug 2019 -Mar 2020), we completed brief phone interviews with 51 caregivers to assess acceptability of provider referral practices, response to developmental concerns, and access to follow-up resources. Participants were average 37 months old, 63% male, 88% spoke English, 57% African American, and 67% had Medicaid insurance. Three pediatric and 2 family medicine providers who practiced at the clinic were interviewed about developmental screening, referral, and barriers to care. Parent and provider interview data were analyzed qualitatively and coded (κ ranging from .71 to 1 and .55 to 1, respectively) using the Consolidated Framework for Implementation Research (CFIR) to identify themes regarding the acceptability, accessibility, and sources of disparities in current developmental care practices.
Results Caregiver data revealed receiving clear instructions, ease of scheduling, and provider follow-up were components of effective referrals, while long wait times, difficulty getting connected to referrals, and the inability follow through with referrals were barriers. Caregivers reported preferring in-depth conversations with provider about delays, handouts, and follow-up appointments with a specialist. Providers identified challenges related to patient needs and resources, networks and communications for both internal and external referrals.
Conclusion(s) Systems-level interventions are necessary to meet the needs of patients and families from diverse backgrounds to ensure developmental concerns are detected early and appropriate resources are provided.
76: Improving Safe Sleep in the Newborn Nursery
Megan Zakerski, Kristen Unsicker, Elise Gross, Maria Skoczylas, Derek Spindler
Purpose: The purpose of this QI project was to conduct a baseline assessment of how often safe sleep was documented and observed by nursing and how frequently safe sleep is reviewed during the newborn hospitalization and then develop interventions for improving frequency of safe sleep. During our assessment, a transition to a specialized nursing postpartum model occurred in October 2021. As part of this staffing reconfiguration, nurses received a refresher on infant safe sleep.
Methods: Providers met with nursing leadership in VVWH to understand the nursing workflow and process regarding documenting infant safe sleep. Safe sleep is documented by nursing during assessments as part of the infant drop risk assessment within flowsheets in MiChart. This data was extracted and analyzed for babies admitted to the newborn nursery from April 2021 to February 2022 (n=4,381). The frequency that safe sleep was documented and whether safe sleep was reviewed by nursing staff during their newborn hospitalization was calculated for each month. The introduction of the specialized postpartum nursing model was considered during the review.
Results: Safe sleep was observed in approximately 85% of nursing assessments between April 2021-February 2022. Safe sleep was reviewed by nursing staff during 74% of newborn hospitalizations during that same time period. There was no difference following the transition to the specialized postpartum nursing model in October 2021.
Conclusion: Based on this baseline needs assessment, safe sleep is being reviewed 74% of the time during the newborn hospitalization, with room for improvement. Observation of adherence to safe sleep best practices during the newborn admission suggest that increased review of safe sleep is needed. We plan to meet with nursing leadership to discuss these results and develop a multidisciplinary intervention. We aim to improve safe sleep review from 74% to 90% over a 6-month period following our next intervention.
77: Expediting Discharge for Infants Acquiring Oral Feeding Skills and Tube Weaning from the Comfort of Home with Telehealth Home NG Clinic
Natalie Morris,1 Catherine Joppich,3 Megan Schmuckel,1 Christine Ndagije,1 Kimberly Monroe,2 Melissa Andersen1
Objectives: The objectives of the outpatient clinic are to 1) decrease hospital length of stay, 2) support parents to use evidence-based feeding practices, 3) facilitate safe, efficient oral feeding skill acquisition and tube weaning from home, 4) promote adequate growth and weight gain, 5) prevent long-term feeding tube dependency and feeding disorders, and 6) increase access to specialized feeding support statewide through telehealth services.
Design/Method: The Cue-Based Feeding team screened infants admitted after birth to identify eligible patients to discharge to the Home NG Follow-Up Clinic once they have achieved at least 30% PO and were medically ready for discharge. All patients were followed via telehealth within 1 week of discharge and weekly until weaned from the NG tube. The main outcomes gathered included number of bed days saved (decreased length of stay), number of tubes weaned, weight, g-tube placement, feeding-related readmissions, and parent satisfaction. Outcome data were collected via chart review and parent satisfaction surveys administered at discharge. This project was supported by funds from the Center of Medicare and Medicaid Services through the Michigan Department of Health and Human Services and from Michigan Health Endowment Fund.
Results: Pilot data demonstrate clinical efficacy, feasibility and high levels of parent satisfaction. Thirty-nine patients have been discharged to the outpatient Home NG Follow-Up clinic, resulting in 193 days decreased length of stay (average of 5 bed days per patient). Average weight gain was 29.7 grams/day, with 100% of tubes weaned by a median of 1 month of age. All patients at risk of g-tube placement were weaned from their NG tubes. Fifteen percent of the patients lived over 50 miles from the institution.
Conclusion: This model of care provides increased access to effective and specialized multidisciplinary care which promotes efficient, successful tube weaning, prevention of long-term feeding problems, and high levels of parent satisfaction.
78: PHARYNGITIS GUIDELINES IN THE AMBULATORY SETTING; A REVIEW OF COMPLIANCE
Kendra Brown #1, Courtney Nugent #1, Heather Burrows1 (#Equal Authorship)
Methods: A retrospective chart review was conducted which looked at patient encounters from the eight different Primary Care facilities within Michigan Medicine Pediatrics between October 2019 - December 2019 for patients presenting with a chief complaint of pharyngitis. Our initial query identified 1,793 encounters which were stratified to separate the encounters in which the SmartSet was used, which was found to be 407 of these encounters and 1,386 encounters in which the SmartSet was not used. In discussion with an institutional statistician, it was determined that to detect a difference of approximately 10% of appropriate antibiotic use in SmartSet vs non-SmartSet users, a total of at least 504 charts would need to be reviewed. The Michigan Medicine Ambulatory Adult and Pediatric Pharyngitis Guidelines was reviewed, and qualifying patient encounters were assessed based on their compliance with these guidelines.
Results: SmartSet users were compliant with University of Michigan guidelines 91.7% of the time (n=233) compared to non-SmartSet users who were compliant only 85.8% of the time (n=217). A chi-square analysis was performed, which demonstrated there was no statistical difference in compliance between those using SmartSets vs those not using SmartSets (p=0.336).
Discussion: While SmartSet users were more compliant than non-SmartSet users, there was no statistical difference between these two groups. There were limitations to our research including small sample size and time since initial study leading to physician turnover and not knowing there is a smart set. Our research did however reveal that there are common areas between both SmartSet and non-SmartSet users where non-compliance with guidelines is the highest including sending PCRs for patients > 16 years old and inappropriate dosing of antibiotics. Thus, our study revealed particular areas for improvement moving forward, and opportunities for further education.
79: RESIDENT-PREPARED CHALK TALKS FOR MEDICAL STUDENT EDUCATION- A QUALITY IMPROVEMENT STUDY
K. Ramos1; E. Boulger1; M. Neelakantan1; E. Jacobson1
Methods: A pre-assessment survey from 2020 was utilized in order to improve and create new chalk talks for medical student education in Jan 2021. Feedback encouraged more visual aids and case-based teaching. Post-survey was distributed to all students who had completed their pediatrics rotation Feb-Dec 2021. Feedback obtained focused on the methods in which residents taught students, and whether or not chalk talks were useful for these educational sessions. A post-assessment survey was also distributed to all categorical pediatrics and med-peds residents focusing on comfort level teaching medical students and beneficial adjustments to chalk talks. A two proportion Z-test was performed to assess for statistical significance.
Results: Of the 38 medical student respondents, approximately 76% received formal teaching overall during their pediatric rotation, with chalk talks being incorporated into 71% of these sessions. This was an increase in utilization of chalk talks from the pre-assessment survey (51% from a sample size of 45 medical students), which was found to be significant with a p = 0.019. 66% of students found chalk talks to be the most helpful form of teaching, citing a combination of elements including pictures, flowcharts, case presentations, and brainstorming sessions as useful techniques. While the percent increased to 56%, this result was not significant (p = 0.41). Of the 18 resident respondents, approximately 37% had used the prepared chalk talks. This was increased from the prior PDSA cycle (32%) but was not found to be a significant difference (p=0.72). 68% of residents agreed or strongly agreed that having available prepared chalk talks increased willingness to teach students, and 55% of residents believed having chalk talks increased teaching skills.
Conclusions: In continued attempts to improve the methods of teaching students during their pediatrics rotation, this study demonstrated the utility of chalk talks along with the large stride of improvements that are yet to be made. The limited responses from residents (18 respondents out of 105 categorical, med-peds, pediatric genetics, and pediatric neurology residents) made it difficult to ascertain the overall opinion of chalk talks from the resident perspective. In regards to the medical students, survey results demonstrate an increase in utility and application of chalk talks as an educational tool; this should continue to be improved upon in future PDSA cycles.
80: EVALUATING THE IMPACT OF VIDEO-BASED SUMMARIES FOR CLINICAL PRACTICE GUIDELINES IN PEDIATRICS
Emile Muallem; David A. Stewart
Objective: Translating Pediatric clinical practice guidelines (CPGs) to video based format may lead to increased utilization of guidelines and perhaps improved clinical practices in our institution.
Design/Method: The project incorporates a pre-video survey with three components including a needs assessment, current understanding of current CPG information, content review, and demographic information. Two pediatric CPG’s were utilized based on perceived resident need, difficulty of topic, and expected utilization in clinical practice. The videos were completed using digital software and include introduction information, review of flowsheets and management guidelines. The pediatric CPGs are both 5-7 minutes in length and in the process of being reviewed by faculty, including relevant stakeholders and CPG authors before being distributed to house officers this upcoming academic year.
Results: A total of 73 responses were obtained from house officers via a Qualtrics survey in October 2021 and indicate that 93% surveyed had managed neonatal hyperbilirubinemia and 86% surveyed had managed bronchiolitis. Of those who indicated they had managed hyperbilirubinemia, 82% of them had referred to the CPG and of the house officers who managed bronchiolitis, 87% of them had referred to the corresponding CPG. The most helpful sections of the CPGs were noted to be figures and graphics (45%), management (text) (36%) and diagnostic information (10%). When asked which barriers most prevented utilizing CPG’s in clinical practice 46% of respondents stated locating CPG was the largest barrier followed by length of CPG and lack of time (36% each). When asked how likely residents would be to watch a 5-7 minute video with n=66, responses indicated a mean of 3.29, STD 1.25, variance 1.57 with nearly 56% of house officers (37/66) indicating they are somewhat or extremely likely to watch.
Conclusion: Data suggests that house officers find both locating CPG and time constraints as leading limitations to utilizing CPGs, as well as length of CPGs. House Officers state that the most helpful part of CPG is images/charts/flowsheets and majority would be interested in video CPG (56%). Clinical practice guidelines change frequently so videos can become outdated soon after release which was a limitation of the study.
REVISION OF THE PARENT ACCEPTANCE OF PEDIATRIC INTEGRATED CARE SURVEY
R. Birnbaum, A. Cook, D. Haggerty, L. Turnier, H. McCaffery, T. Tope-Banjoko
Objectives: The primary objectives of the project were to update the PAPICS by including questions regarding virtual behavioral health service delivery, revise existing questions to improve internal consistency estimates, and validate the newly designed, chosen survey model.
Design/Method: The PAPICS was revised (PAPICS-R) with a team of experts in IBH pediatric primary care. The Qualtrics Online Panels Service was used to distribute the PAPICS-R to a diverse sample (n = 834) of parents with children under 18-years old. Exploratory and confirmatory factor analyses were then performed with independent samples.
Results: The resulting chosen factor model for the PAPICS-R consisted of 42 items and 5 factors with higher internal consistency estimates than the original version (α = .845 to .923).
Conclusions: The PAPICS-R offers IBH pediatric primary clinics at the University of Michigan Health and other medical systems a tool to better serve parents and children in their community. Gaining insights into parent perspectives on IBH and appropriately addressing their concerns and misperceptions could result in a much needed increase in children, adolescents, and their families accessing behavioral health care.