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Pediatric Abstract and Poster Competition Friday, May 3, 2019The Metropolitan, MinneapolisMedical StudentsR/QIElli JacobsonMonica Gressett Hall, Paul Strain, Zineb Alfath, Anne Gair, Uyen Truong, Christopher Desjardins, PhD, Andrew Olson, MD, Johannah Scheurer, MD, Eileen Crespo, MDOral Health for Physicians: Incorporating Oral Health Education into Medical Training. Many physicians and medical students overlook their patients’ oral health. Physicians may fail to examine or treat patients’ oral health because they believe it is the dentist’s realm, do not think it is relevant to patients’ overall health, or lack adequate knowledge and training. Despite its importance, there are limited opportunities in medical school curricula to learn about patients’ oral health. To help fill this educational gap, we developed and evaluated a session dedicated to oral health for University of Minnesota Medical School students. Students learned how to complete an oral health exam, how to apply fluoride varnish, and how oral health is integral to patients’ overall health. This session is one effort to better educate medical students on this topic. Dissemination of an effective workshop model and curriculum may improve the disparity in oral health care education. Methods: Our group designed a session for third and fourth-year medical students. The session included content didactic, patient cases, and hands-on demonstrations. The session objectives were: ● Understand how to evaluate patients for caries, gingivitis, and other common oral health conditions ● Recognize oral symptoms of systemic conditions ● Identify evidence-based outpatient treatments that have an effect on patients’ oral health ● Review the importance of oral health and how disparities in oral health impact patients ● Discuss HPV-associated oropharyngeal cancer and other topics of interprofessional collaboration with dental providers Students completed voluntary pre and post-quizzes (immediately and one month following the course) designed in Qualtrics to gauge understanding of the material. Descriptive statistics and t-tests for significant change in mean score were completed with R software. Results: Third-year students (n=84 of 203 enrolled, 41% response rate) and fourth-year students (n=78 of 180 enrolled, 43% response rate) both showed a significant score improvement from the pre-quiz to the immediate post-quiz (p<.001 for both classes). Scores improved 13.0% for third-year students and 16.2% for fourth-year students, demonstrating that both classes improved their scores by one question on the 10-question quiz after attending the course. On a post-quiz one month later, scores of third-year students (n=59) and fourth-year students (n= 52) significantly improved from pre-intervention (p<.001 for both classes). Conclusion: The oral health workshop was a valuable tool for students to learn about an important topic otherwise lacking in their curriculum. Teaching future physicians about oral health will aid them in understanding the public health implications and importance of oral health as well as enable participation and comfort in providing another essential aspect of preventative care. Future directions include a refresher video for session attendees, opportunities for hands-on practice of oral health exams, and dissemination of the curriculum longitudinally across the medical education continuum.R/QICurtis BashoreTaylor Wells, Sameer Gupta MDImproving the Sensitivity of an Automated Score to Assess Risk of PICU Transfers. Intro: This quality improvement (QI) project is aimed at creating a predictive PICU risk score in order to reduce the number of unplanned PICU transfers at University of Minnesota Masonic Children’s Hospital (UMMCH). While this scoring system will not prevent all unplanned transfers, it could trigger physicians to watch patients with high PICU risk scores more closely, which may minimize interventions needed upon arrival in the PICU. Methods: A PICU risk score was established in UMMCH’s electronic health record, Epic, in which a patient’s score is automatically generated every four-hours based on their vitals, medications, and past medical history. This QI project is currently in its fourth PDSA, with both retrospective and prospective data sets. The most recent PDSA revised the previous scoring algorithm, by adding a new prediction variable (length of stay), removing a previous prediction variable (prior PICU stay), and reassigning the PICU risk score threshold based on the patient’s floor. The latter is because patients on the bone marrow transplant floor often have higher risk scores than patients on the two medical/surgery floors Results: Across the first three PDSAs, the score’s sensitivity improved from 30% to 70%, and the specificity declined from 88% after first read with PDSA 3 to 80%. The current PDSA (#4) has not been established long enough to determine whether the score sensitivity is increased from the previous PDSA. However, early data have the specificity at 92%, which is very promising. Additionally, based on the retrospective data, 57% of patients who were transferred to the PICU had a score at or above the PICU risk score threshold established. Conclusion: UMMCH is a leader in creating a PICU risk score that is automatically generated in the patient’s electronic health record. In the first few PSDA cycles, there have been fluctuations in the sensitivity and specificity values, but with each cycle we aim to increase these measures. Additionally, continually analyzing the reason for individual patient’s PICU transfer will provide us with insight to improve the scoring algorithm. In order to make this score clinically relevant and useful, we will continue to use the prospective and retrospective data to refine the scoring algorithm to make it a more sensitive measure. R/QIMarvin SoTamekia ParkerRacial/Ethnic and Income Disparities in Flourishing among Minnesota’s Children – National Survey of Children’s Health, 2016-2017 Background: Decades of knowledge regarding the negative consequences of adverse childhood experiences has prompted recent interest in instead characterizing child well-being from a strengths-based lens. Flourishing is a state characterized by positive social, emotional, and psychological functioning in children, which can be affected both by a child's own health status as well as broader socioecological factors. Characterizing parent’s reports of child flourishing at the state level, along with potential differences by sociodemographic factors, could highlight the needs of specific communities and illuminate opportunities for intervention. Methods: We conducted a weighted analysis of the National Survey on Children’s Health combined 2016-2017 dataset to examine parent reports of flourishing among children in the state of Minnesota. Flourishing was operationalized using two sets of developmentally-appropriate indices developed by the U.S. Maternal-Child Health Bureau: resilience, curiosity, affection/tenderness, and smiling/laughing (for children ages 0 – 5 years) and resilience, curiosity, and task persistence (for children ages 6 – 17 years). Consistent with previous research (Kandasamy, et al., 2018), children needed to fulfill all items in the measure “usually” or “always” in order to be classified as flourishing. We calculated weighted prevalence proportions, 95% confidence intervals (CI), and prevalence ratios (PR) to estimate flourishing overall, by race/ethnicity, and by household income. Results: In Minnesota, 68.2% (95% CI: 61.0 – 74.7) of children ages 0-5 and 40.9% (95% CI: 36.8 – 45.2) were perceived by their parents to be flourishing; both rates were higher than the nationwide average. For children in both 0-5 and 6-17 age groups, children who were Hispanic, Black, Asian, and Other demonstrated significantly lower rates of flourishing compared to non-Hispanic White children (PR range: 0.47-0.98), with the exception of Asian children ages 6-17 (non-significant difference). We observed lower rates of flourishing with consecutively decreasing income levels, such that children in families with household incomes <100% of the federal poverty level (FPL) showed significantly lower rates of flourishing compared to those in the highest income category (>400% FPL), for both children ages 0-5 (PR: 0.66, 95% CI: 0.43 – 0.86, p<0.01) and ages 6-17 (PR: 0.62, 95% CI: 0.43 – 0.82, p<0.01). Discussion: Our findings illustrate that Minnesota’s families report higher rates of child flourishing compare to national averages, but that differences by race/ethnicity and household income exist. Health and social service systems could target child flourishing (e.g., social and emotional learning programs) to potentially yield improvements in health, social, and economic outcomes and address persistent disparities.R/QISayarath MayaKathleen WaddicorReducing the lost to follow-up rate among adolescents and young adults. Introduction: The Adolescent/Young Adult Program at Boston Children’s Hospital serves a diverse population of patients from ages 10-25 and provides not only primary care but also subspecialty gynecological, nutritional, as well as psychological care. In an initial study within the clinic, it was found that 10% of pregnant teen were lost to follow-up (LTF), which is defined as patients who did not return to clinic and their outcomes are unknown. Reducing the LTF rate is essential to providing high quality patient care and to ensuring continuity in medical services between primary care clinics and outside prenatal and/or termination services for patients with a pregnancy diagnosis. Methods: A pregnancy intake form was completed by the provided and utilized to maintain a weekly log of newly diagnosed pregnancies. The LTF rate and average length of time between the pregnancy diagnosis and completed referral appointment was tracked. Primary intervention included establishment of a new collaboration with the Beth Israel Deaconess Medical Center (BIDMC) and Brigham and Women’s Hospital (BWH) and the Adolescent Teen Program to confirm dates of first prenatal appointments and improve follow-up communication. Results: The LTF rate remained the same as last year at 4.8%, remaining under 10% for the second consecutive year. There was a 1.6% increase in the number of pregnancies diagnosed this year (2017-2018) when compared to last year (2016-2017), from 62 pregnancies to 63 pregnancies. This year the interval between pregnancy diagnosis and referral appointment was 23.6 days in comparison to last year’s 23.4 days. The rate of prenatal care referrals showed a decrease from last year, from 61.3% (2016-2017) to 55.6% (2017-2018). The number of ectopic pregnancies remained at zero for the third consecutive year. The rate of miscarriages increased from 4.8% to 12.7%, while the rate of terminations decreased slightly from 29.0% (2016-2017) to 27.0% (2017-2018). Repeat pregnancies increased between last year and this year from 32.3%to 49.2%. Discussion: Maintaining a LTF rate under 10% was accomplished by collaborating with the Adolescent Teen Program at BIDMC and BWH. The consistency in the number of total pregnancies and reduction from roughly 100 pregnancies/year several years ago, may be due to the number of IUD and Nexplanon insertions in the Adolescent Practice. The increase in referral time is related to clinicians seeing more complex care patients with pregnancies involving referral to specialists. While great advances were made this past year, next steps will include developing an Evidenced Based Guideline for providers to ensure consistent pregnancy follow-up care, development of resource materials for patients for referral, and finally, continuing to utilize and expand collaboration with the Adolescent Teen Program at surrounding hospitals to ensure a LTF rate under 10% in the coming year.R/QIMarvin SoBaila Elkin, Tobias Donlon, Anna Dovre, Katherine Beck-Esmay, Kristin Chu, Kylie Blume, Christina DaraganAdvancing Effective Healthcare for Sexual and Gender Minority Pediatric Patients: An Evaluation of the LGBTQIA+ Symposium. Advancing Effective Healthcare for Sexual and Gender Minority Pediatric Patients: An Evaluation of the LGBTQIA+ Symposium Background: Multi-level factors including stigma, social inequity, and lack of awareness among healthcare providers drive health disparities experienced by LGBTQIA+ populations. To address this, the University of Minnesota Sexual and Gender Minority Health Initiative organized a three-hour Symposium focusing on care for LGBTQIA+ children and youth. We hypothesized that participating in the Symposium, involving interprofessional didactic and active learning components, would promote increased effectiveness working with this population. Methods: 67 individuals completed a retrospective post-then-pre evaluation survey. Respondents included graduate students (48%), undergraduate students (12%), healthcare providers (21%), and community members (19%). The survey assessed five indicators of Symposium effectiveness: knowledge about this population, comfort in discussing their healthcare needs, confidence in finding resources, comfort in interacting with this population, and comfort in recommending care for this population. We conducted 1-tailed paired t-tests to evaluate the effectiveness of the Symposium, and ANOVA tests to compare differences by professional role. Results: Participants reported significantly higher (p<0.001) scores across all five measures of effectiveness from pre- to post-Symposium. By role, scores significantly improved (p<0.05) for all measures except comfort in interacting with LGBTQIA+ pediatric patients or clients among (1) undergraduates and (2) community members. Although not significant, we found a trend showing healthcare providers seeing the greatest value and relevance in the Symposium’s active-learning component compared to other groups. Groups who did not find the session relevant (average rating of <4 on a 1 -5 scale) found it useful in contextualization. Conclusions: Our results indicate that the Symposium was effective in increasing participants’ effectiveness in serving LGBTQIA+ pediatric patients, even within the short timeframe. This demonstrates that an educational model, including interprofessional didactic and active learning components, is an effective way to increase proficiency in pediatric LGBTQIA+ health competencies that may not be sufficiently addressed by traditional medical education.CSThomas Taylor Kharmene Sunga, MDConsiderations for Glutaric Aciduria Type 1 in the Workup for Non-accidental Trauma: Case Presentation and Literature Review Considerations for Glutaric Aciduria Type 1 in the Workup for Non-accidental Trauma: Case Presentation and Literature Review Background Subdural and retinal hemorrhages in young children with minor mechanisms of injury suggest non-accidental trauma (NAT) but can be seen in patients with glutaric aciduria type 1 (GA1), a rare inborn error of metabolism detectable on newborn screening1-3. Characteristic clinical features provide clues for diagnostic distinction 1, 2, 4, 5. Case Presentation: A 7-month-old developmentally normal male presented to a tertiary emergency department (ED). He was presumed to have fallen backwards while seated with subsequent bilateral leg shaking, limpness and emesis. CT head showed bilateral hygromas with acute left-sided bleeding. No surgical intervention was required. NAT workup revealed multilayered retinal hemorrhages. Skeletal survey was unremarkable. Social work discovered the patient lives with his mother (five years methamphetamine-free), while his father is imprisoned for substance use. Urine organic acid testing uncovered hydroxyl glutaric academia, a very rare inborn error of metabolism similar to GA1. Ultimately his presentation was deemed consistent with GA1, but NAT could not be ruled out. The patient was discharged with a safety plan. Two months later, the patient returned to the ED. While in his mother’s arms the patient’s head bumped into a chair. He lost consciousness, turned blue, and vomited. Head CT showed expanding chronic subdural hematoma and increased head circumference. After chart review and literature search, NAT evaluation was pursued. Skeletal survey was unremarkable. Ophthalmalogic examination revealed improving intraretinal hemorrhages. Due to intermittent emesis and lethargy, neurosurgery was consulted without need for intervention. He was discharged after five days with instructions for weekly head circumference monitoring. Discussion GA1 is an autosomal recessive disorder of lysine, hydrozylysine, and tryptophan metabolism, caused by glutaryl-CoA dehydrogenase deficiency1, 2, 5-7 (United States prevalence 1:50,000)6. GA1 commonly presents before age 18 months with sudden onset encephalopathy and extrapyramidal symptoms2, 7. Although neuroimaging is variable, frontotemporal atrophy, widening of Sylvian fissures and abnormalities of basal ganglia in a macrocephalic child should raise suspicion1, 4, 5, 7. Subdural hematomas may be discovered at first presentation1, 2, 4, 5, 8. Cerebral atrophy increases shear stress across elongated bridging veins. Intraretinal and subhyaloid hemorrhages have been reported less commonly1-4. Children with GA1 may be irritable with developmental delays, leading to parental frustration and risk for NAT2, 4. A normal skeletal survey is a key diagnostic aid as GA1 neither predisposes patients to fractures nor causes skeletal abnormalities1,2. Conversely, subdural hematomas have only been reported in the presence of the aforementioned characteristic neuroimaging features1, 2. Lack of these concurrent findings should heighten clinical concern1, 2. Summary Though GA1 can cause findings mimicking NAT, clinicians should remain vigilant for intentional harm. The skeletal survey can aid in differentiation and remains a prudent first step1, 2. CSKatherine KelseyPaige Partain, MD, Angela Mattke, MDChest Pain and a Clarinet: A Case of Spontaneous Pneumothorax Background: Adolescents presenting with non-traumatic chest pain in the primary care setting require a thorough assessment. The differential diagnosis of pediatric non-traumatic chest pain is wide and work-up must include assessment for presence of respiratory distress, hemodynamic stability, and obtaining a detailed history and physical examination. Case Description: A 17 year old male presented to his outpatient pediatric clinic with new onset acute chest pain. History was significant for anorexia nervosa, exercise-induced asthma, autism spectrum disorder, and major depression. While playing the clarinet in band class, he had sudden onset left-sided throbbing chest pain that radiated to his back. The pain progressively worsened and became sharp with deep breathing. Toward the end of the class period, he became dizzy and nauseated. He was evaluated by a school nurse and vital signs were appropriate. As his pain did not significantly improve, he presented to primary care for further evaluation. He was not in respiratory distress. No history of trauma, coughing, wheezing, inhalation of drugs, or smoking prior to the onset of chest pain. There was a family history of Long QT syndrome in his father, but no family history of collagen, vascular, or genetic disorders. Physical examination showed decreased breath sounds on the left and chest x-ray demonstrated a small-moderate sized left pneumothorax. An EKG was unremarkable. He was diagnosed with a spontaneous pneumothorax. After consultation with a pediatric pulmonologist, given lack of respiratory distress and small-moderate size, it was decided to monitor as an outpatient. Despite clinical improvement, a follow-up chest x-ray three days later showed enlargement of the pneumothorax. He was admitted to the general pediatrics hospital service for oxygen therapy and serial x-rays. Upon admission, respiratory status remained stable and he was started on continuous 15L/min 100% via non-rebreather facemask. After 48 hours on 100% oxygen, the pneumothorax did not show improvement. A chest CT was performed for risk stratification and demonstrated moderate left pneumothorax, mild dependent left-sided atelectasis, and tiny apical blebs bilaterally. Due to failure to resolve with non-operative management, a thoracoscopy, blebectomy, and wedge resection were performed and chest tube placed. Post-operatively, the pneumothorax was decreased and the chest tube was removed without complications. He was discharged on post-operative day two. On one week follow-up, chest x-ray demonstrated a very small residual left pneumothorax. He denied shortness of breath, chest pain, and was recovering following the surgical operation without complication. Conclusion: In adolescents presenting with non-traumatic chest pain, a comprehensive history and attentive physical examination will aid in approaching the potential wide differential. Spontaneous pneumothorax is diagnosed by chest radiograph, history of sudden onset pleuritic chest pain, and diminished breath sounds on physical examination.CSNelson, GruszczynskiGajanthan Muthuvel, Erin Knoebel, Ellen McMahon, Siobhan PittockSeizures, Hypoglycemia and Ketosis: What is the Beta Cell Doing? Background: A 19 month-old African American girl with a history of epilepsy presented in status epilepticus with a blood glucose of 36 mg/dL. The seizures occurred within 2 hours of a large meal. She had several additional seizures in the setting of normoglycemia. Endocrine and metabolic panels were unremarkable, with only mildly elevated ammonia. Vital signs were within normal limits. Weight, length and head circumference were appropriate. She was alert. No evidence of trauma was seen. Cranial nerves, strength and sensation appeared intact. Development was age appropriate. Description of work: A 24 hour diagnostic fast was conducted, resulting in hypoglycemia (central blood glucose 29 mg/dL) at 17.5 hours associated with inappropriate insulin and C-peptide levels. Her blood glucose responded appropriately to IV glucagon administration (increasing from 29 mg/dL to 69 mg/dL in 15 minutes). In addition, she had an elevated beta-hydroxybutyrate. Presence of inappropriate insulin and c-peptide in the setting of hypoglycemia and response to glucagon confirmed hyperinsulinism. The presence of high ammonia levels and the pattern of post-prandial hypoglycemia pointed to hyperinsulinism-hyperammonemia (HIHA) and genetic testing revealed the patient has a heterozygous variant in the GLUD1 gene.? Reflections: HIHA syndrome is most commonly due to a missense mutation in GLUD1, producing glutamate-dehydrogenase (GDH) with reduced sensitivity to its allosteric inhibitors, ATP and GTP. This leads to increased depolarization of the beta-cell membrane and secretion of insulin (Fig. 1). Treatment includes a low protein/leucine diet and diazoxide. The hypoglycemia is often less severe in this condition than other metabolic disorders and hyperammonemia is asymptomatic. This patient tolerated a fast for 17 hours before becoming hypoglycemic. Over that time period, she developed ketosis which is a normal response to fasting. Her laboratory profile also showed hyperinsulinism and her response to glucagon confirmed that hyperinsulinism was the cause of her hypoglycemia. While investigating for potential causes of hypoglycemia, the presence or absence of ketosis typically drives the diagnostic direction. The presence of ketosis usually rules out hyperinsulinism. Our case illustrates that the presence of the GLUD 1 mutation does not interfere with the normal pattern of ketosis with fasting. Typically, patients with hyperinsulinism will not tolerate as long of a fast as our patient did, as they usually exhibit insulin hypersecretion prior to development of significant ketosis. Ultimately, her diagnosis was delayed due to the presence of epilepsy, which can be seen with HIHA. The presence of ketosis was also a confounder. High ammonia levels in the setting of epilepsy should trigger an evaluation for HIHA.R/QIJohn ScheuerAnne SchmiesingPrescribing Video-Based Patient Education in the Hospital Setting: Effect on Exclusive Breastfeeding Rates at Discharge Background: Despite usage of videos for discharge education, a paucity of literature exists evaluating their effectiveness. Since discharge for postpartum mothers is standardized and high in volume, we focused on this population. Additionally, exclusive breastfeeding at discharge is a predictor of breastfeeding success at home and is therefore tied to a measurable and positive health outcome. Objective: Evaluate the impact of educational videos on the rates of exclusive breastfeeding at postpartum hospital discharge. Methods: In November 2015, we added four breastfeeding education videos to the newborn admission set and tracked videos watched. We generated a dataset including all healthy term (37 .0 - 41.6 week) infants, eliminating those with stays longer than 4 days, and babies that were SGA or LGA. We captured 12 months before and after the intervention (eliminating the month of initiation). We compared exclusive breastfeeding rates pre and post intervention and compared rates between mothers who watched any videos in the post-intervention period vs those who watched none. Results: Our final dataset included 2,685 infants (1,467 pre- and 1,218 post-intervention). Postintervention, the exclusive breastfeeding rate was 68.6% compared to 68.4% pre-intervention, and the exclusive formula feeding rate was 4.4% post vs 4.8% pre. 986 mothers (81%) watched all four videos, and 230 (19%) watched none. The mothers who watched all four videos were more likely to breastfeed exclusively (71.8% vs 54.3%) and less likely to exclusively formula feed (1% vs 19.1%). Conclusion: There was no meaningful change in exclusive breastfeeding rates pre vs post intervention. However, mothers who watched the videos were more likely to attempt any breastfeeding (99%) compared to those who watched none (80.8%). While this may speak to increased engagement of those already wishing to pursue breastfeeding, more study is needed to determine if the video intervention contributed to increased willingness to breastfeed.CSSydney LarkinMegha M. Tollefson, MD Julia S. Lehman, MD Ashley B. Wentworth, MDA case of extensive acquired progressive lymphangioma ABSTRACT: Acquired progressive lymphangioma (benign lymphangioendothelioma) is a rare lymphatic anomaly of unclear pathogenesis. Excision is generally advised for localized disease, although other therapies have been trialed. This report describes a unique case of extensive acquired progressive lymphangioma involving the abdomen, genitalia and lower extremity of a one year old male. Rapid progression and multi-site involvement in this young patient required exploration of non-surgical options for management. REPORT OF CASE: A one year old infant boy presented with an erythematous plaque on his abdomen, which had been slowly enlarging over the prior seven months. The affected area began as several smaller papules that coalesced to involve the majority of his lower abdomen and peri-umbilical skin. His parents reported intermittent episodes of darkening along the plaque borders. Family history was non-contributory. Previous biopsies at his local institution were non-diagnostic, showing a perivascular interstitial monocytic infiltrate with lymphocytes. Complete blood count, peripheral blood smear, prothrombin time, international normalized ratio, urinalysis, and computerized tomography scan of the abdomen were normal. No prior therapies had been trialed. Physical examination at the time of presentation revealed a 12- x 15-cm plaque with ecchymotic discoloration along the borders (Figure 1). Two biopsies, taken from the right abdomen and the suprapubic area, showed irregularly-shaped, ectatic vessels throughout the dermis (Figures 2 and 3). Endothelial cells marked with FLI-1, CD34, and D2-40, but were negative for WT1, HHV-8, CD3, CD20, and CD68, supporting the diagnosis of APL. Abdominal and pelvic ultrasound did not reveal an associated vascular anomaly or other intraabdominal or pelvic masses. MRI of the abdomen and pelvis with contrast revealed an expansive, infiltrative process involving subcutaneous tissues of the anterior abdominal wall, right hip, groin, and scrotum. Macrocystic components or intraabdominal extension were not present. The patient’s clinical involvement was noted to be progressive, spreading to the penis, right scrotum, and lower extremity, with accompanying episodic pain. Taken together, clinical exam, histopathology, and imaging were consistent with a diagnosis of acquired progressive lymphangioma. Surgical excision was precluded by the extent of this vascular anomaly. As such, systemic treatment with sirolimus was advised; however, the patient was lost to follow-up after nine months of care at our institution. Pediatric ResidentsR/QIVishal Naik, MDJohannah Scheurer, MD; Samreen Vora, MD; Rahul Kaila, MD; Suzanne Nelson, MD; Mindi Driehorst, MD; Mark Roback, MD; Glenn Paetow, MD; Emily Borman-Shoap, MDPerformance under pressure: the use of EPAs to standardize pediatric mock code evaluation Background: Pediatric mock code simulations play a critical role in the development of a trainee’s decision making ability in otherwise high-pressure situations that she or he may not routinely encounter. To ensure that trainees are receiving maximal benefit from these simulations, it is important that they receive optimal, timely feedback. Description of work: A prospective, observational study of pediatric residents at the University of Minnesota, Children’s Hospital Minnesota, and Hennepin County Medical Center is underway. The aim of this educational intervention study is to evaluate the use of the American Board of Pediatrics’ entrustable professional activities (EPAs) for mock code education and to characterize an implementation process of doing so. To ensure consistency of experience and increase resident exposure to a breadth of cases, a standardized mock code curriculum was created amongst the three hospital systems. The curriculum of cases includes emergencies of airway, breathing, circulation, disability/neurologic emergencies and trauma. An online assessment tool was then created utilizing the American Board of Pediatrics’ EPAs as a method of one-to-one feedback between instructor and trainee immediately following the conclusion of the mock code. At the end of the formative feedback, the trainee and the instructor complete a Likert scale question evaluating perceived utility of using EPAs as assessments following the mock code. Data on overall EPA completion rate will be gathered. Conclusions: As a feedback model that is novel in pediatric mock code simulation, results from this study will serve as a pilot for future EPA-based simulation evaluations with potential implications for ED, PICU and NICU fellow training. Reflections: This project has allowed me to appreciate the process of making change at the system-wide level. I had to identify key stakeholders in important conversations and better appreciate the importance of thorough planning and patience when making large changes. I am learning about the different methods of giving quality, meaningful feedback that will prove important to me as a chief resident and future educator. At project initiation, there was modest coordination between the three pediatric hospital systems as to the content and organization of pediatric code preparation. Our trainees need to know how to think critically in high pressure situations, and I believe that this project is a small step in a more organized approach in doing so.R/QISharmila Raghunandan, MDNathan Wegmann, DO; Paul George, Deogratius Bakulumpagi, Derrick Bengo, Phillip Kasirye and Peter WasswaPeripheral Blood Smear as a Diagnostic Tool for Sickle Cell Disease in a Resource Limited Setting Peripheral Blood Smear as a Diagnostic Tool for Sickle Cell Disease in a Resource Limited Setting Introduction: Sickle cell disease (SCD) is the most common hereditary hematologic disorder worldwide with greater than 90% of SCD births occurring in low resource settings including sub-Saharan Africa (SSA). The gold standard for diagnosing SCD is hemoglobin electrophoresis but it is often unaffordable or unavailable in low resource settings that have the highest burden of SCD. Instead, cheaper tests such as a peripheral blood smear (PBS) have been used to diagnose SCD. However, few studies have been conducted to assess the validity of a PBS as a diagnostic tool for SCD. The primary goal was to measure the sensitivity and specificity of a PBS for the diagnosis of SCD and the secondary goal was to evaluate the PBS characteristics of patients with SCD. Methods: A two-gate case–control study was conducted between January and March 2019, during which patients with SCD (Hb SS/Sβ0 thalassemia) and controls with anemia were enrolled with a ratio of 3 SCD patients to 1 non-SCD patient with anemia. A laboratory technician and hematologist, both of whom were blinded from each other and from whether the PBS was from an SCD or non-SCD participant reviewed the PBS. Using a standardized form, they assigned likelihood of SCD diagnosis as definite (presence of numerous sickled cells), probable (presence of other characteristics without multiple sickled cells) or negative based on review of each slide. The laboratory technician further reviewed each PBS for sickled cells, target cells, Howell-Jolly bodies, normoblasts and polychromasia. Results: A total of 154 participants were recruited and data analysis was run on 149 participants (102 SCD and 47 non-SCD) aged 1 to 18 years. The specificity was 100% (95% CI 94 - 100) for both reviewers and sensitivity was 88.2% and 70.5% for the laboratory technician and hematologist respectively, when ‘definite’ was utilized as a positive test. The specificity decreased to 87.2% and 97.6% and sensitivity increased to 98% and 95.8% for the laboratory technician and hematologist respectively, when ‘probable’ was included. The interrater agreement for the laboratory technician and hematologist for positive SCD (definite and probable) versus negative SCD was high (96% agreement, kappa 0.897, standard error 0.085). Sickled cells were seen exclusively in PBS of SCD participants. Howell Jolly bodies and target cells were seen more frequently in PBS of SCD participants while polychromasia and normoblasts were commonly seen in PBS of SCD and non-SCD participants. Conclusion: In a resource limited setting where the burden of SCD is high, the use of PBS to diagnose SCD is highly specific, arguing against the need for confirmatory testing. Furthermore, examination of PBS by experienced individuals looking for features of SCD can be a sensitive test for pediatric patients presenting with anemia. R/QIErin Bakrat, MDJeffrey Louie, MD; Marissa Hendrickson, MDPreventing pain: Improving Pain Management During Infant Lumbar Punctures in the ED, a quality improvement initiative Background: Lumbar puncture is an important diagnostic tool for evaluation of the febrile infant. This procedure is potentially painful for patients, and emotionally distressing to families. The AAP recommends analgesic use during lumbar puncture to minimize distress. Further, performance of this procedure without analgesia in a young infant has potential lasting emotional effects. Oral Sucrose has been advocated as a valuable analgesic for infants undergoing procedures10 however, recent evidence suggests that it may not offer as effective analgesia as expected. The goal of this project was to identify analgesics use during LP procedures and establish a system of procedural analgesic administration. Methods: We utilized PDSA cycle methodology to initiate a multifaceted interventional approach involving providers, nursing staff and the Electronic Medical Record. Data was abstracted using ICD-10 code for lumbar puncture. Chart review data was collected for a 12-month pre-intervention period in 2017 and a 12-month intervention period in 2018. PDSA Cycle 1 included: ED staff educational infographic poster, ED staff acknowledgement of initiative, initial and ongoing resident and nursing education, and modification of LP dot phrase. PDSA Cycle 2 included an informational poster with 6-month progress and repeat nursing staff teaching. Results: 100 LP procedures were performed, 52 pre-intervention and 48 intervention. Group comparison demonstrated no significant difference in mean ages, gender, resident attempt at LP, or number of puncture attempts. Use of 1 analgesic was increased to 100% from 98.1% pre-intervention. Use of 2+ analgesics was increased to 87.5% from 57.7%. Procedural success rates increased to 93.8% from 90.3%. LMX utilization was increased to 72.5% from 55.8%. This increase did not result in a decrease in the use of injectable lidocaine during procedure. Further, we examined success rates per number of analgesics in the combined cohort of 100 patients. 1 method elicited a 92.8% success rate, 2 methods elicited a 94% success rate and 3+ methods elicited a 90.5% success rate Conclusion Implementation of educational interventions and collaboration between health care providers created a successful environment for improving patient care during an LP procedure. Through these interventions, we obtained 100% compliance with use of at least one form of analgesia and demonstrated a formidable increase in the use of two forms of analgesia. Additionally, our results demonstrate that triage nurse education and empowerment helped produced an increase in the use of the LMX analgesic by 30%. Further, this intervention did not produce a negative effect on the use of injectable lidocaine. Through this project our staff became familiar with a staged process for pain management and testified to increased awareness in preventing pain in this population. The overall success of this project was dependent on staff collaboration and engagement in pain management for this vulnerable population. CSJeremy Taylor, MDTo breathe or not to breathe, a case of stridor in question A 5-year-old boy with Juvenile Idiopathic Arthritis (JIA) and a 1-year history of persistent stridor at rest thought to be due to vocal cord dysfunction presented to the Emergency Department (ED) for respiratory distress secondary to worsening stridor. He was given racemic epinephrine and steroids with no improvement. He underwent flexible laryngoscopy in the ED that demonstrated normal larynx with no evidence of paradoxical vocal cord motion. He was admitted to pediatric intensive care unit (PICU) for further evaluation where he was promptly scheduled for a direct laryngoscopy and bronchoscopy. During the procedure, he was noted to have significant subglottic edema. He underwent balloon dilation and had kenalog injections in his subglottic tissue. Superficial biopsies of the tissue were taken that demonstrated squamous metaplasia and keratinization. He arrived back to the PICU intubated. He failed multiple extubation trials for two consecutive days despite treatment with steroids. Tracheostomy was then pursued to secure his airway and during the procedure, a full thickness biopsy of his trachea was taken. The biopsy demonstrated chronic inflammation in the cartilage rings. Based on the biopsy results, Rheumatology believed that his diagnosis was more consistent with Relapsing Polychondritis (RPC) rather than his previous diagnosis of JIA. The remainder of his clinical course was stable with establishment of immunosuppressive therapy. RPC is a rare immune mediated condition that is associated with inflammation in cartilaginous structures throughout the body, particularly the ears, nose, eyes, joints and respiratory tract. Early manifestations are usually subtle and remain unrecognized for prolonged periods. As a result, the diagnosis is often delayed and made after emergence of classic features such as auricular inflammation or saddle nose deformity. No known clinical or laboratory measures predict the overall disease course. Men and women are affected equally. The disease occurs at all ages and in all races. Approximately one-third of cases occur in the setting of another recognizable condition such as vasculitis, connective tissue diseases and malignancies. CSErin McHugh, MDDaniel Beisang, MD; William Gershan, MDProgressive respiratory failure in term neonate with 45X/46Xr mosaic Turner’s Syndrome, suspicious for Filamin A syndrome. Case: Patient is a 5 month old full-term female with pregnancy complicated by IUGR, oligohydramnios, and multiple fetal anomalies. She displayed respiratory failure on DOL1 necessitating intubation. Given the patients multiple anomalies, chromosomal microarray was obtained and resulted significant for 45x/46Xr mosaicism, consistent with mosaic Turner’s Syndrome and ring X chromosome. Her respiratory status progressively declined, requiring increases in her ventilator settings. Imaging was obtained including Chest CT which revealed significant architectural distortion and interlobular thickening of the interstitium consistent with ILD, and brain MRI which showed foci of subependymal nodular gray matter heterotopia as well as white matter loss and agenesis of the corpus callosum. Flexible bronchoscopy was performed with normal visualized airway structures. In combination with her progressive respiratory failure and abnormalities of the lung parenchyma on chest CT, her MRI findings of periventricular heterotopia raised concern for Filamin A deficiency. After discussion with both neonatology and pulmonary care teams, genetic testing was performed and remains pending. She continues to display progressive respiratory decline complicated by multiple pneumothoraces and increasing ventilator requirements. Discussion: Filamin A deficiency is the result of mutations in genes that encode for the actin cross-linking protein Filamin A. These mutations have been associated with various forms of severe lung disease, cardiac disease, and periventricular heterotopia demonstrated on this patient’s MRI. Filamin A resides on the X-chromosome and is inherited in an X-linked recessive fashion. Several X-linked recessive genetic disorders have been described in the setting of females with XO karyotype including Hemophilia and Duchenne Muscular Dystrophy. This case represents the first description of Filamin A deficiency occurring in an XO female, highlighting the need to consider X-linked genetic diseases in this patient population. Conclusion: Here we present the first description of a female with XO/Xr mosaic Turner’s syndrome with severe and progressive respiratory failure and multiple clinical features consistent with Filamin A deficiency. While confirmatory genetic testing remains pending, we are pursuing high dose steroid bursts as treatment approaches, as previously described. This case highlights the importance of remaining vigilant for childhood interstitial lung disease, particularly in infants with otherwise an inappropriate degree of lung disease for their clinical scenario. CSJessica Hane, MDNever Make Diagnostic Assumptions: A case of acute psychosis in a 10-year-old Anti-NMDA receptor encephalitis is an autoimmune disease characterized by antibodies against N-Methyl-D-Aspartate receptors in the brain. A previously healthy 10-year-old female presented to the emergency department with headache and psychosis. Family reported that patient became acutely unable to feed herself, ran around the house naked, and commented “I have to get through this brick wall.” She experienced 3 days of headache, nausea, vomiting and diarrhea prior to mental status changes. She was afebrile and hemodynamically stable. Complete blood count, comprehensive metabolic profile, C-reactive protein, urine hCG and urine drug screen were unremarkable. A MRI showed a normal brain and a pelvic ultrasound was negative for a mass. Lumbar puncture revealed an opening pressure of 34 and WBC of 67. She was started on empiric acyclovir and ceftriaxone. Her mental status continued to deteriorate with development of myoclonic jerks, oral dyskinesia, and behavioral outbursts which prompted transfer to the PICU for sedation. She was started on high dose methylprednisolone 1g daily with little improvement. On HOD 6, CSF oligoclonal bands returned positive and IVIG treatment was initiated. On HOD 7, CSF NMDA antibody returned positive, confirming the diagnosis of anti-NMDA receptor encephalitis. Treatment course included high dose steroids, rituximab, and repeat doses of IVIG. She received speech, occupational, and physical therapy. She was stable for discharge 43 days after admission. This case illustrates the importance of testing for anti-NMDA receptor encephalitis in patients presenting with new-onset psychosis or mania. It also highlights the prolonged clinical course for patients with anti-NMDA receptor encephalitis despite prompt and appropriate treatment. CSAlice Lehman, MDAcquired prothrombotic state in a pediatric patient with severe H1N1 This case demonstrates influenza a virus (IAV) acquired dysregulation of coagulation in a pediatric patient; a rare, albeit morbid IAV associated complication and highlights the need for further recognition in pediatric populations. A 30-month-old unimmunized female presented in septic shock. She was aggressively fluid resuscitated, started on two vasopressors, and intubated. Examination was significant for delayed capillary refill in distal extremities. Her work up revealed left lower lobe opacity, significantly elevated inflammatory markers, and a positive nasal PCR for pandemic H1N1. She demonstrated persistent signs of arterial insufficiency in distal extremities despite resuscitation. Ultrasounds revealed occlusive thrombi of bilateral ulnar arteries, left radial artery and venous thrombi of right subclavian and cephalic veins. Labs demonstrated critical deficiencies of protein C(PC), protein S(PS), and antithrombin3(AT3), with disproportionate elevation of Von Willebrand Factor (vWF). Supportive management included systemic TPA, factor replacement with fresh frozen plasma and antithrombin 3, and medicinal leech therapy. Despite these interventions, her left upper extremity underwent necrosis of metacarpals and with additional development of a necrotic lung lesion. Upon medical stabilization, she transitioned to enoxaparin and is undergoing staging for amputation of her left upper extremity. IAV is well described to activate cytokines, chemokines, endothelial cells (EC) and platelets leading to dysregulated coagulation cascades (1,2). Our patient experienced a cytokine storm leading to an acquired deficiency of AT3, PC, PS, and disparately elevated vWF. This prothrombotic state led to diffuse arterial and venous thrombi and suspected thrombotic microangiopathy resulting in limb ischemia and lung necrosis. Arterial and venous thrombi are poorly described in pediatric patients with IAV. Vascular and microvascular thrombi are mediated through disruption of EC via cytokines, including TNF-alpha, IL6, IL1, IL8, and IAV RNA, leading to release of tissue factor and vWF (1,2,3,4). Literature suggests adults with IAV demonstrate an increased risk of acute myocardial infarct and ischemic stroke, as well as deep venous thrombosis and pulmonary embolism (5). A review of adults with pH1N1 found 5.9% of patients experienced clinically significant vascular thromboembolisms (6). Further retrospective data on pH1N1 correlated immune dysregulation with worse patient outcomes, thus prompting investigation into role of immunomodulator therapies to halt excessive cytokine release (7). Early recognition of IAV associated coagulation dysregulation may have changed our patient’s outcomes, however limited pediatric literature on this subject often delays supportive management. Detection of acquired coagulation dysregulation is important in critically ill pediatric patients with IAV. Our patient’s critical limb ischemia demonstrates IAV acquired prothrombotic state leading to arterial and venous thrombi. In pediatric patients this phenomenon requires further research as early recognition could significantly change a patient’s morbidity. Furthermore, investigation into immunomodulators to dampen cytokine storm is mandated to prevent IAV associated morbidity and mortality in pediatric patients (7). CSSandy Liu, MDEric Velazquez, MD, Jeff Louie, MD, Bradley Miller, MD, PhDCase Report: 17 year old female presenting with throat pain, a case of pediatric myxedema with hypothyroid myopathy and pericardial effusion Case Presentation: A 17 year old female presented to an outside hospital with one day of throat pain, chest tightness, and swelling in her fingers, face, and feet. She denied any recent skin, hair, or nail changes, constipation, abdominal pain, palpitations, large fluctuations in weight, or changes in fatigue level. She reported intermittent URI symptoms for the last week. She said she has always had cold intolerance. Her parents reported that she had been talking more slowly than normal and that she had difficulty responding to questions appropriately. Her menstrual periods were very regular. She denied recent illnesses, coughs, congestion, joint pain, or rash. At the outside emergency department (ED), her physical exam was notable for non-pitting edema of the face, hands, and feet, an erythematous posterior oropharynx, and chest wall pain. EKG showed bradycardia, small P waves, and low voltage QRS waves. Troponin, Monospot, and d-dimer were negative. A chest x-ray, obtained due to pleuritic pain, was negative. Prior to transfer to University of Minnesota Masonic Children’s Hospital (UMMCH) ED, she was noted to have down trending systolic blood pressures to the 80s, with sustained bradycardia into the low 50s, despite two NS boluses. She was transported via helicopter and had improved blood pressures en route. Bedside echocardiogram in the UMMCH ED confirmed pericardial effusion. She was admitted to the general pediatrics service. There is a significant family history of both hyperthyroidism and hypothyroidism. Her TSH on presentation was significantly elevated to 89.8 [0.4-4.0 mU/L], free T4 of 0.2 [0.76-1.46 ng/dL], CK elevated at 1089 [30-225 U/L], ALT of 295 [0-50 U/L] and AST of 138 [0-35 U/L]. She had elevated anti-TPO antibodies of 669 [<35 IU/mL] and ANA to 160 [negative]. Thyroglobulin antibody, complement, and ds-DNA antibodies were negative. Discussion: This patient’s presentation of facial and peripheral edema, hemodynamic instability initially unresponsive to fluid resuscitation, and mental slowing without electrolyte imbalance was suggestive of myxedema coma. Popoveniuc, et al. developed a scoring system to evaluate likelihood of myxedema coma diagnosis, with a score >60 being highly suggestive/diagnostic [1]. Our patient clearly qualified for 50 points on their criteria but had three additional criteria that were questionably met, for an additional 30 points confirming this categorization. A literature search was completed on Pubmed. Using search terms “Child” and “Myxedema” resulted in 250 articles, of which 122 were in English, of which only 6 articles described pediatric cases of myxedema coma [2-7]. Pericardial effusion and myopathy are known, but uncommon, complications of profound hypothyroidism, but there is no case in the literature that describes a pediatric case of myxedema coma with both complications concurrently. References: 1.Popoveniuc G, Chandra T, Sud A, Sharma M, Blackman MR, Burman KD, Mete M, Desale S, Wartofsky L. A diagnostic scoring system for myxedema coma. Endocrine Practice. 2014 Aug; 20(8):808-17. 2.Vierucci F. Severe hypothyroidism due to autoimmune thyroiditis in a child: a one-year follow-up. Hormones (Athens). 2014 Oct-Dec;13(4):583-4. doi: 10.14310/horm.2002.1508. Epub 2014 Nov 5. 3.Clements SA, Travers SH. Supraclavicular swelling in hypothyroidism. Curr Opin Pediatr. 2011 Aug;23(4):482-5. doi: 10.1097/MOP.0b013e3283481ad4. 4.Schutt-Aine JC. Hypothyroid myxedema and hyponatremia in an eight-year-old child: a case report. J Natl Med Assoc. 1980 Jul;72(7):705-8. 5.Herman SP, Burgert EO Jr. Anemia and growth failure. Clin Pediatr (Phila). 1976 Oct;15(10):962. 6.Sakurada T, Saito S, Yamaguchi T, Yoshida K, Yamamoto M. Tohoku. The changes of serum triiodothyronine, thyroxine and thyroid stimulating hormone in two cases of hypothyroidism with unusual complications. J Exp Med. 1974 Apr;112(4):365-71. 7. McGirr EM, Hutchinson JH. Dysgenesis of the thyroid gland as a cause of cretinism and juvenile myxedema. J Clin Endocrinol Metab. 1955 Jun;15(6):668-79.CSTrisha Paul, MDCJ Koozer, Daniel CortezA Pupil Blown Out of Proportion: Unilateral Mydriasis Caused By A Rare Offender We present a 5 year old male with single ventricle physiology (RV dominant AVSD), transposition of the great vessels, pulmonary atresia s/p RV to PA conduit, who suffered from a respiratory-mediated cardiac arrest during catheterization requiring 20 minutes of CPR and ECMO resulting in HIE also with atrial tachycardia. Baseline neurologic exam included minimal responsiveness to stimuli, global hypotonia, and bilateral clonus. Twenty four days following cardiac arrest, new findings included the left pupil 5mm round and reactive to light and the right pupil 8mm round and fixed. Non-contrast CT head showed no acute intracranial hemorrhage or mass effect and was consistent with known anoxic brain injury. CT head and neck angiogram with contrast showed patent vasculature with no evidence of thrombosis. The differential included increased intracranial pressure, acute ischemic or hemorrhagic stroke, adverse medication effects, or subacute symptoms due to previous anoxic brain injury. The patient had no bradycardia or hypertension to suggest increased ICP or herniation. Recent episodes of atrial tachycardia and the presence of a surgical cardiac conduit increased the risk of ischemic stroke secondary to thrombus, but he had been on daily aspirin therapy. Imaging showed no evidence of hemorrhagic stroke, although CT cannot rule out an ischemic stroke. Active medications known to cause unilateral mydriasis included ipratropium nebulizer treatments and topical clonidine. Ipratropium, an anticholinergic nebulizer treatment for respiratory clearance, had most recently been administered 4 hours prior. The clonidine patch had been switched from the left shoulder to the right shoulder 4 days prior. Given improvement in pupil asymmetry without removal of the clonidine patch, unilateral mydriasis was determined to be caused by droplets from the recent ipratropium nebulizer treatment which had made contact with the right eye due to incomplete mask seal, causing anticholinergic-induced mydriasis.CSSharon Li, MDPale Blue Dot: Evolution and Management of Congenital Dacryocystocele A term female born at 40 weeks 4/7 days gestation was brought to her primary care physician at 2 weeks of life for routine well child check. Her parents noted at that time that she had some swelling of her left eyelid near the nasolacrimal duct since birth. No discharge or induration was noted at the time, and parents were encouraged to apply warm compresses to the area daily. A referral to ophthalmology was made for further evaluation of the lesion. She was seen in ophthalmology clinic at 3 weeks of life and was found to have had worsening of the swelling around her tear duct, now with a central area of bluish underlying the mass. Additionally, the area had started draining purulent fluid. The child had otherwise been feeding, growing, and doing well—review of systems was negative for fever, fussiness, or changes in feeding, stooling, or urination. She was diagnosed with a left dacryocystitis as a complication of congenital dacryocystocele, which was unable to be probed in clinic. Due to her young age and concern for spread of the infection, the patient was admitted to a tertiary care facility for IV antibiotics followed by probing of the lesion in the OR by ophthalmology. Culture of the eye drainage grew Haemophilus influenza and Haemophilus parainfluenzae. The lesion improved on ceftazidime and clindamycin, and on hospital day 4, the patient underwent probing of her left lacrimal duct in the OR, which she tolerated well. We transitioned IV ceftazidime and clindamycin to oral augmentin, and the lesion completely resolved by the end of the 7 day course of antibiotics. While typical nasolacrimal duct obstructions results from imperforate membrane at the distal end, dacryocystoceles result from occlusion of proximal and distal portions of the nasolacrimal duct and represent a variation of nasolacrimal duct obstruction; they are relatively rare, accounting for 0.1% of congenital nasolacrimal duct obstructions [1]. While the majority of nasolacrimal duct obstructions present in the first weeks to months of life with excessive tearing, congenital dacryocystoceles tend to present shortly after birth, typically as a bluish mass at the medial canthus. Rarely, dacryocystoceles present solely intranasally [2]. As in this patient, dacryocystoceles can become infected within days to weeks after birth and develop into dacryocystitis, which requires treatment with IV antibiotics and probing of the nasolacrimal sac. While simple dacryocystoceles are amenable to probing in the clinic, those that are infected or complicated often requiring probing in the OR after 24-48 hours of antibiotics. While the differential of canthal swelling is broad and includes encephalocele, hemangioma, and dermoid cysts, this case underscores the importance of remembering dacryocystocele and dacryocystitis as a cause of mass in the nasolacrimal duct region, especially in neonates in whom control of local infections must be timely in order to prevent systemic complications.CSHannah Giunta, DORewarming to Death: The Use of ECMO in Hypothermic Drowning Background: A previously healthy, 9-year-old boy presented to the Mayo St. Mary’s ED status post-near drowning. He was playing with his brother on a local lake when he fell through the ice and was submerged for at least 90 minutes before rescuers could pull him from the water. He received at least 60 minutes of CPR prior to ED arrival. In the ED, the boy was hypothermic and hemodynamically unstable. He was then cannulated for ECMO. His initial head CT showed profound loss of white-grey matter differentiation. He was coagulopathic and started on the massive transfusion protocol. EEG demonstrated a lack of cerebral electrical activity. After several hours on ECMO, the circuit stopped, and the patient expired. Description of Work: While the team agreed the patient’s prognosis was almost certainly fatal, the general consensus was that we could not know his prognosis definitively until he was warm. In addition, providers shared anecdotal experiences of miraculous outcomes in near drowning patients. I assisted with writing orders during the resuscitation and was called by the blood bank after his transfer to the ICU. As part of the team that cared for this child in the emergency room, it prompted a review of the use of ECMO for rewarming, as well as the general outcomes for drowning victims. Lastly, I reviewed the allocation of the scarce resources involved in the case—namely ECMO and blood supply. Implications: This case brings both medical and ethical issues to the forefront. Case discussions are personal and powerful but must be tempered by more robust, long-term data analysis. A series of miraculous cases does not a definitive treatment make even when no other viable treatment options remain. Additionally, while I often theorize about resource allocation as a medical ethicist, I have never had to engage in bedside rationing decisions with individual patients. Yet, deploying resource-intensive interventions could have impacted the options that remained for my other patients that evening. Finally, while I appreciate the general principle that you must be warm before death is declared, there are circumstances where a person is truly both dead and cold. The type of decision being made (i.e. declaration of brain death before organ donation) may influence the absolute need for rewarming as well. From an ethical standpoint, this case raises questions about informed consent, autonomy, and justice. There are circumstances where resource-intensive therapies ought not to be offered, even though a slim hope for a miracle remains. CSLeah S. Heidenreich, MDRobert J. Macielak, Meghan Cain, MDNeck Pain in a 9-year-old Boy Background: A previously healthy, immunized 9-year-old male is referred to the Emergency Department for evaluation of six days of worsening fever, fatigue and anterior neck pain. Medical history is pertinent for environmental allergies and chronic rhinitis. Surgical history is pertinent for adenotonsillectomy, performed four years prior for chronic congestion and tonsillar hypertrophy. On arrival to the Emergency Department, the patient appears unwell but non-toxic. His vital signs are normal when awake. When sleeping, he is sonorous with oxygen saturations of 80-85%. Physical examination reveals a large white plaque posterior to the uvula. This seems to be causing obstruction when supine. The oropharynx otherwise appears normal, without asymmetry, evident palatine tonsils or mass. Based on history and examination, our initial differential diagnosis includes sepsis, meningitis, deep neck space infection, epiglottitis, LeMierre’s disease, viral pharyngitis, influenza and other viral respiratory illnesses. We are less concerned for tonsillitis, in the setting of prior adenotonsillectomy. Laboratory evaluation reveals leukocytosis (16.3), normal basic metabolic panel and elevated C-Reactive Protein (CRP) (93.7). Blood cultures and a swab from the site of the plaque are obtained. A CT neck is obtained in order to characterize the precise location and composition of the plaque. This reveals acute, uncomplicated adenoid tonsillitis, which is ultimately supported by clinical examination. Reflections: Our original differential diagnosis did not include adenoid tonsillitis, based on the patient’s history of adenotonsillectomy. However, unlike routine palatine tonsillectomy, adenoidectomy does not involve complete removal of all lymphoid tissue, based on the indistinct nature of the adenoid pad border [1]. As a result, there is risk of adenoid tissue regrowth. This is typically subclinical, if present at all, and the need for revision adenoidectomy is estimated to be less than 1% [2-4]. However, remnant and even minimally regrown adenoid tissue can become infected, resulting in acute adenoid tonsillitis despite prior surgical intervention. Timely diagnosis and treatment of acute adenoid tonsillitis are critical, particularly when the oropharyngeal inflammation has resulted in an obstructive process. Therefore, a thorough oropharyngeal examination and a high index of clinical suspicion for adenoid tonsillitis, even in the setting of prior adenoidectomy, are crucial in providing appropriate patient care. References 1. Liapi A, Dhanasekar G, Turner NO. Role of revision adenoidectomy in paediatric otolaryngological practice. J Laryngol Otol. 2006;120(3):219-221. 2. Buchinsky FJ, Lowry MA, Isaacson G. Do adenoids regrow after excision? Otolaryngol Head Neck Surg. 2000;123(5):576-581. 3. Joshua B, Bahar G, Sulkes J, Shpitzer T, Raveh E. Adenoidectomy: long-term follow-up. Otolaryngol Head Neck Surg. 2006;135(4):576-580. 4. Monroy A, Behar P, Brodsky L. Revision adenoidectomy--a retrospective study. Int J Pediatr Otorhinolaryngol. 2008;72(5):565-570.FellowsR/QILeslie Kummer, MDJanna Gewirtz O'Brien, MD; Johanna Scheurer, MD; Andrew Olson, MDMaking an Impact Through Advocacy: Description and evaluation of a medical student workshop Background: Given the impact of social determinants on individual and community health and pervasive health disparities in the United States, advocacy is increasingly recognized as a core component of medical professionalism. Advocacy curricula for medical students have been described, but most are focused exclusively on legislative advocacy or are designed as elective blocks with 20-100 hours of instructional time. It is unclear whether a brief advocacy training workshop can influence medical students’ knowledge, self-efficacy, and intention to engage in advocacy during their careers. Objectives: 1) To identify the baseline health advocacy experience, knowledge, self-efficacy and intentions of third year medical students participating in an elective workshop; 2) to describe and evaluate the impact of a 90-minute advocacy training on medical student knowledge, self-efficacy and intention to engage in health advocacy. Methods: An interactive, elective advocacy workshop was implemented with third year medical students, exploring the meaning of advocacy, highlighting examples of physician advocacy during and after training, and developing advocacy plans. Students were invited to complete a survey before and after the session using 7-point Likert-scaled responses. We utilized descriptive statistics to describe baseline experience, knowledge, self-efficacy and intention to engage in advocacy during their careers. We then conducted paired t-tests to evaluate the effectiveness of the session. Results: A total of 100 students were enrolled, of whom 74 (74% response) completed the baseline survey and 35 completed both pre- and post-surveys. At baseline, 46% had experience in advocacy and, on a 7-point Likert scale (7 being the strongest agreement), students reported that there were opportunities for physicians to advocate (6.4+/-0.68), conceptualized advocacy as part of their physician identity (5.9+/-1.3), and felt motivated to engage in advocacy (5.7+/-1.0). However, they reported limited power (4.9+/-1.2) and skills (4.3+/-1.4) to effect change. Among those who completed both pre- and post- surveys, participants reported significant increases in knowledge (mean score 5.3, increased to 6.5, p<0.05), conceptualization of “advocate” as an important part of their professional identities (5.9 vs 6.2, p<0.05), sense of empowerment (5.1 vs 5.9, p<0.05), and perceived skill to effect change through advocacy (4.2 vs 5.6, p<0.05). Those who completed the post-survey were no different at baseline than those who did not. Conclusions: Our findings suggest that medical students are interested and motivated to be engaged in advocacy, but may lack self-efficacy and skills. This brief workshop shows promise of enhancing knowledge and self-efficacy regarding advocacy. Further research is needed regarding how to best cultivate and sustain physicians-in-training as advocates. R/QIHeidi Kamrath, DO, FAAPDaniela Villacis Calderon, MD; Erik Norbie, BA; Kelly McManimon, MSW, Dannell Shu, BFA, MWS; Anne Woll, MS; Naomi Goloff, MD, FAAP, FAAHPM; Johannah Scheurer, MD, FAAPPediatric End-of-Life Simulation Program: A Novel Educational Approach for Pediatric Fellows Purpose: Pediatric end-of-life (EOL) care is a high-stakes situation requiring careful planning and practice; there is only one chance to get it right. While several pediatric subspecialties commonly treat patients with life-threatening illnesses, fellowship training often lacks formal EOL training and skills practice. In this study we evaluated a half-day simulation-based workshop to determine feasibility and benefit to pediatric subspecialty fellows for their confidence and competence in EOL skills. Methods: Neonatal-Perinatal Medicine, Pediatric Hematology-Oncology, Blood and Marrow Transplant, and Critical Care fellows plus Advanced Practice Providers were invited to participate. Pre-intervention training background and confidence surveys (Likert agreement scales) were completed. The educational intervention included: a pre-briefing introduction, two small-group team-based immersive simulations, an EOL skills station, and a large-group debriefing. For each simulation two facilitators completed a performance checklist (multiple items within domains of: appropriate context, common understanding, family education, closure, and global performance) and led a structured debriefing using PEARLS framework (). Interdisciplinary facilitators included pediatric subspecialty faculty, chaplains, nurses, social workers, and bereaved parent faculty. Participants repeated confidence surveys both immediately and 3 months after the session. To assess the change in confidence responses, Wilcoxon signed-rank tests were performed. Results: During the first year of programming, 34 participants attended at least one workshop; most completed both the pre- and immediate post-surveys (n=32, 94%). Of 28 first-time attendees, only 7% (n=2) reported having had “a great deal” of formal teaching or observation in providing EOL care. Trainee confidence for providing EOL care significantly increased for 5 of 9 surveyed skills (p<0.03 for all). The most increased confidence ratings were for EOL skills related to compassionate extubation: ordering medications (mean score increase 0.7, SD 0.7, p=0.01) and managing symptoms (mean score increase 0.9, SD 0.6, p=0.002). 3 month follow-up surveys from the initial 17 participants revealed that 94% (n=16) reported incorporating the EOL workshop training into clinical practice. Analysis of trainee qualitative survey responses and performance checklists for common areas of trainee strengths and improvements is forthcoming. Conclusion: A half-day simulation workshop is an effective way to practice, teach, and integrate pediatric EOL care skills, helping to fill an educational gap. Findings suggest the workshop content is relevant to participants’ clinical practices. Future project directions include workshop dissemination, expanding interprofessional educational opportunities, and longitudinal assessment of trainee confidence, competence, and emotional impact of the workshop. R/QIJanna R. Gewirtz O'Brien, MDLaurel D. Edinburgh, MSN, APRN; Annie-Laurie McRee, DrPHaRunning the risk: A comparison of mental health outcomes among runaway, homeless, and stably housed youth A comparison of mental health outcomes among runaway, homeless, and stably housed youth Background/Objectives: Runaway youth and homeless youth are at risk for adverse health outcomes, including mental health disorders. These two populations are frequently pooled together in both research and interventions, yet may have unique health needs requiring targeted services and policies. We sought to assess differences in mental health outcomes among these populations. Methods: We conducted a secondary data analysis using responses of 9th and 11th graders in the 2016 Minnesota Student Survey (n=71,897). We compared four subgroups of youth based on their housing status in the prior year: those who: (1) had run away (“runaways”); (2) had experienced unaccompanied homelessness (“homeless”); (3) had both runaway and been homeless (“both”); and (4) had stable housing (“stably housed”). We assessed demographics and primary care utilization, then performed multivariable logistic regression to compare 4 mental health outcomes (depressed mood, self-injury, suicidal ideation, suicide attempts) between groups, controlling for demographics and abuse history. Results: Overall, 4.8% of youth had runaway, 0.5% had been homeless, and 0.6% had been both. All 3 of these groups had poorer mental health outcomes when compared to their stably-housed peers (p<.05). For example, 21.0% of runaways, 10.9% of homeless youth, and 32.9% of youth in the both group had attempted suicide in the prior year, compared with 2.4% of stably-housed youth (aORs= 5.0, 2.2, and 6.6, respectively). Other outcomes showed a similar pattern. Among youth in the homeless and both groups, 58% had received well-child care in the prior year, compared with 64% of runaway and stably-housed youth (p<.05). Conclusions: Our findings suggest that runaway and homeless youth represent unique populations with high mental health needs that would benefit from targeted interventions. Levels of well-child visits across all groups highlight the potential of primary care as a point of screening and intervention.R/QITaylor Argo, MDKathleen K. Miller, MD, FAAP, Tori Bahr, MD, Alexandra Prince, Christy Boraas, MD, MPH, Nicole Chaisson, MD, MPH, Emily Borman-Shoap MD, FAAP, Janna R. Gewirtz O’Brien MD, FAAPNo Missed Opportunities: A trainee-driven long acting reversible contraceptive workshop for pediatric primary care clinicians Purpose: The American Academy of Pediatrics (AAP) recommends long-acting reversible contraceptives (LARCs), including intrauterine devices (IUDs) and etonogestrel implants, as first-line contraceptive methods for adolescents, yet fewer than 5% of adolescents ages 15-19 use these methods. Though pediatric providers are well-positioned to provide LARCs, barriers include provider knowledge, attitude and experience, leading to missed opportunities to prevent teen pregnancy. Our initial needs assessment identified that the majority of community pediatric providers were not providing LARCs. A survey of pediatric trainees revealed that 88% desired LARC training. To meet these needs, we implemented a LARC workshop for pediatric trainees and community providers. The objective of this study is to assess the impact of our intervention and report provider intentions to recommend and deliver LARC methods after the workshop. Methods: Pediatric residents on their adolescent medicine rotation and community pediatric providers participated in a 3.5-hour workshop, offered monthly starting in July 2018. The workshop included an interactive educational session on LARC methods, followed by hands-on etonogestrel implant training and certification. We assessed participant knowledge, comfort, attitudes, and intention to deliver LARCs using a brief survey. We used a 5-point Likert scale for all measures, with the exception of knowledge, which used a 4-point scale. In addition to descriptive statistics for all measures, we conducted independent sample t-tests to compare knowledge, comfort and attitudes before and after the workshop. Results: A total of 106 clinicians have participated in the workshop- 42 medical residents and fellows (40%), 42 advanced practice providers (40%), and 21 attending physicians (20%), from the fields of pediatrics or medicine-pediatrics (61%), family medicine (21%) and women’s health (13%). Participants reported significantly improved knowledge (implant: pre 2.8 / post 3.8, p<0.05; IUDs: pre 2.9 / post 3.5, p<0.05) and comfort with counseling (implant: pre 3.8 / post 4.7, p<0.05; IUDs: pre 3.9 / post 4.4, p<0.05) after the workshop. Clinicians who participated were more likely to recommend a LARC method (pre 4.6 / post 4.9, p<0.05). Eighty-nine percent of participants were likely or very likely to place etonogestrel implants in their clinical practice after the session. Conclusions: Clinicians who attended the workshop reported increased knowledge and comfort with LARC methods, and were more likely to recommend and provide a LARC method in their clinic. Uniquely, this intervention was trainee-driven in collaboration with a multidisciplinary team that engaged partners across the University, community, industry, and professional organizations. If clinicians were to increase LARC provision, this could translate to improved LARC access for adolescents in the primary care setting. ................
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