2015 Eastern SPR Annual Meeting - American Pediatric Society

Transcription

2015 Eastern SPR Annual Meeting
Abstract Number: 1515
Filename: 754934
Publication Number: 72
Presenting Author: Necla Kudrick, MD
Department/Institution/Address: Pediatrics, Division of Newborn Medicine, 100 Woods Rd, Valhalla, NY, 10595, United States
Phone: 7186900439
Fax:
Presenting Author E-mail: [email protected]
Is Presenting Author a Trainee? No, Not a Trainee
Presenter Copyright Declaration:
I certify that any material I will use, display, distribute, reproduce or have reproduced or distributed in connection with my above noted presentation for which I do not have permission to use, is my original work and/or
is public information or another type of material which does not require securing permission from another party to use, display, distribute, reproduce or have reproduced or distributed.
Title: Elevated Turnover of Adrenal TH mRNA in an Animal Model of Hypoglycemia Associated Autonomic Failure
Necla Kudrick1, Edmund F. LaGamma1 and Bistra Nankova1. 1Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center New York Medical College, Valhalla, NY.
BACKGROUND: Hypoglycemia triggers the release of epinephrine (Epi), activation of tyrosine hydroxylase (TH) enzyme and catecholamine biosynthesis in the adrenal medulla (AM). HAAF (hypoglycemia associated
autonomic failure), as a result of recurrent hypoglycemia is characterized by defective Epi response to subsequent hypoglycemia. Although the effect of recurrent hypoglycemia on counter-regulatory hormonal
responses has been well characterized, the molecular mechanisms underlying the defective counter-regulation are incompletely understood.
OBJECTIVE: We hypothesized that the impaired Epi responses to recurrent hypoglycemia are due to altered adrenal TH gene expression.
DESIGN/METHODS: Adult male Sprague-Dawley rats with vascular catheters (jugular vein & carotid artery for stress-free blood sampling and drug administration) were used. The rats were randomly assigned to 4
different groups (n ≥ 6), and given insulin (2 IU/kg) (RH, 2RH) or saline (S, 2S) injection once per day or twice per day for 3 days. The blood glucose levels were maintained between 40-50mg/dL in insulin group. On
day 4, the animals were sacrificed at 0, 30 or 60th min or 3h after the 90-min hyperinsulinemic-hypoglycemic clamp. AM were removed and frozen at -80C until further analyses. Blood samples were collected during
the clamp for counter-regulatory hormonal levels to confirm the creation of HAAF. The relative rate of transcription and the steady-state TH mRNA levels were measured by northern blot and quantitative RT-PCR.
Statistical analysis was done with significance at p < 0.05.
RESULTS: No significant differences in relative TH gene transcription rate were observed between the groups at 0min or 3h after termination of the clamp. Progressive increases in the relative TH gene transcription
rates were observed during hypoglycemic clamp at 30 & 60min under all conditions. However relative TH mRNA level in 2RH group was significantly reduced 5h after the start of the insulin infusion.
CONCLUSIONS: Adrenal capacity to produce Epi is reduced in HAAF despite the unaffected TH gene transcription consistent with accelerated degradation of TH mRNA. Our current study does not support
tachyphylaxis of the receptors (Sivitz et al., 2001, Herlein et al., 2006). Future research will be necessary to determine whether any other factors exist in vivo (e.g. lipolysis by-products, hormones, etc.) that may evoke
targeted degradation of TH mRNA. This may provide a new therapeutic target in reducing HAAF.
Filename: 750798
Presenting Author: Christine T. Ferrara, MD,PhD
Department/Institution/Address: Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, 11NW, Philadelphia, PA, 19104, United States
Phone: 215-590-3174
Fax: 215-590-3053
Is Presenting Author a Trainee? Yes, Fellow in Training
Title: Congenital Hyperinsulinism Caused by Heterozygous Uncoupling Protein 2 (UCP2) Mutations
Christine T. Ferrara1, Kara E. Boodhansingh1, Elenora Paradies3,4, Arupa Ganguly1, Fiermonte Giuseppe3,4, Ferdinando Palmieri3,4 and Charles A. Stanley1. 1Endocrinology and Diabetes, The Children's Hospital of
Philadelphia, Philadelphia, PA; 2Institute of Biomembranes and Bioenergetics, Consiglio Nazionale delle Ricerche, Bari, Italy; 3Center of Excellence in Comparative Genomics, University of Bari, Bari, Italy and 4Institut
National de la Sante et de la Recherche Medicale, Paris, France.
BACKGROUND: Congenital hyperinsulinism (HI) is associated with nine genetic loci. Inactivating mutations in uncoupling protein 2 (UCP2) were described in 2 patients with diazoxide-responsive HI in 2008, but no
additional cases have been reported. New data on the function of UCP2 indicate that rather than serving as a mitochondrial proton leak, UCP2 is a key regulator of TCA cycle intermediates. Deficiency of UCP2 may
trigger excessive glucose stimulated insulin secretion by enhanced glucose oxidation, thus inactivating mutations in UCP2 may be the etiology of dysregulated insulin secretion in a subset of patients with
hyperinsulinism.
OBJECTIVE: Our objective was to determine the frequency of dominant UCP2 mutations in patients with diazoxide-responsive hyperinsulinism.
DESIGN/METHODS: One hundred eighteen infants with diazoxide-responsive HI seen between 1997-2010 were screened for mutations in UCP2.
RESULTS: UCP2 missense mutations were identified in 3 unrelated infants with diazoxide-responsive HI (3% of all diazoxide-responsive cases). All 3 were of African-American ethnicity and presented with HI prior to
6 months of age. Case 1 had a previously reported mutation (p.A268G) while cases 2 and 3 had novel mutations (p. G61S, p. S47N). Mutations in case 1 and 3 had low level frequency in sub-Saharan Africans (0.01%
and 0.3%, 1000 genome data). In vitro expression studies of all 3 mutations showed reduced UCP2 activity from 20-40% to 60-80% of normal. Case 1 was responsive to diazoxide therapy; diazoxide was partially
effective in cases 2 and 3, but coexisting risk factors may have exaggerated the severity of their HI (SGA birth weight and a possible MODY3 mutation, respectively). Hypoglycemia resolved by the age of 7.5 years in
case 1 and by 11 months in case 2. Case 3 is still on diazoxide therapy at 5 years of age.
CONCLUSIONS: With these 3 patients, there are now a total of 5 cases of UCP2 inactivating mutations as a dominant form of diazoxide-responsive HI. In our series, UCP2 inactivating mutations occurred at a
frequency similar to other rare genetic causes of HI (HNF1a, HNF4a, HADH). Hypoglycemia appears to be a problem primarily in early infancy and may improve or resolve later in childhood.
Filename: 750290
Presenting Author: Christine T. Ferrara, MD, PhD
Department/Institution/Address: The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, United States
Phone: 215-590-3174
Fax:
Title: Disruption of Pancreatic Fibroblast Growth Factor Receptor 1 (Fgfr1) Signaling Impairs Glucose Homeostasis in Female Mice
Christine T. Ferrara1,2, Po Man A. Suen1, Andrea V. Rozo1, Mira M. Sachdeva1, Kathryn C. Claiborn1, David N. Groff1 and Doris A. Stoffers1. 1Endocrinology, Diabetes and Metabolism, University of Pennsylvania,
Philadelphia, PA and 2Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Glucose-stimulated insulin secretion (GSIS) from the β cell is critical for glucose homeostasis and requires precise and rapid responses to external stimuli. Fibroblast growth factors (Fgfs) are among
key islet signaling molecules and alter diverse cellular processes by acting through their receptors (Fgfr). Fgf21 belongs to the newly described endocrine Fgf subfamily abundantly expressed in liver, adipose, and
pancreas, and has beneficial effects on glucose homeostasis.
OBJECTIVE: The aim of the current study was to investigate the role of pancreatic Fgfr1 in glucose homeostasis and pancreatic islet growth and function.
DESIGN/METHODS: We generated Fgfr1LoxP/+; Pdx1-Cre mice (Fgfr1+/∆panc) which have heterozygous deletion of exons 8-15 of Fgfr1 in Pdx-1 derived cells. Fgfr1+/∆panc mice and Fgfr1LoxP/+ ("wild type") littermates
were placed on regular chow (RC) and high fat diet (HFD) for 16 weeks prior to glucose- and insulin-tolerance tests, and pancreatic morphometric analysis. Function of isolated islets was quantified by
glucose-stimulated and Fgf21-stimulated insulin secretion, as well as glucagon secretion.
RESULTS: Female Fgfr1+/ ∆panc mice have impaired in vivo glucose tolerance compared to wild type mice with a loss of first-phase insulin secretion dynamics. This phenotype was exacerbated by HFD. β cell mass
was not compromised in Fgfr1+/ ∆panc mice on either RC or HFD, and there was increased proliferation in response to diet-induced stress, suggesting that the Fgfr1+/ ∆panc mice have impaired insulin secretory dynamics
rather than a loss of insulin producing cells. Glucose-stimulated insulin secretion and insulin content, however, were maintained in isolated islets of Fgfr1+/ ∆panc mice as compared to those from wild type littermates.
Fgf21, a potential ligand for Fgfr1, was upregulated in islets of Fgfr1+/ ∆panc mice. Pre-incubation of islets with Fgf21 caused a modest potentiation of GSIS in wild type islets, an effect that was blunted in Fgfr1+/∆panc
islets.
CONCLUSIONS: Reduction of Fgfr1 results in impaired in vivo glucose tolerance on both RC and HFD without loss of β cell mass or cell number, or ex vivo GSIS. Fgf21-potentiation of GSIS is dependent on Fgfr1,
suggesting that the pancreatic Fgfr1 pathway modulates glucose homeostasis by integrating signals from the islet environment and extrapancreatic organs.
Filename: 755035
Presenting Author: Tami Stuart, MD
Department/Institution/Address: Neonatology, Children's Hospital of Philadelphia, CHOP, Dept of Neonatology, 34th and Civic Center Blvd, Philadelphia, PA, 19104, United States
Phone: 404-368-5744
Fax:
Title: Maternal Obesity Alters Trophectoderm Development
Tami Stuart1, Isaac Sasson2, Kathleen O'Neill2 and Rebecca Simmons1. 1Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA and 2Obstetrics and Gynecology, Perelman School of Medicine UPENN,
Philadelphia, PA.
BACKGROUND: We have previously shown that maternal obesity leads to abnormal placentation in a mouse model. Placentas derived from mice fed a high fat diet weigh less than those on a control diet and display
decreased invasion into the maternal endometrium. This could lead to changes in nutrient delivery to the developing fetus and contribute to the abnormal metabolic phenotype seen later in life. As fetal and placenta
growth restriction was observed already at e12.5, we hypothesized that early placenta (trophectoderm) of mice fed a high fat diet would display alterations in genes involved in placenta development and invasion
when compared to trophectoderm derived from mice fed a control diet.
OBJECTIVE: To determine the effects of obesity on gene expression in mouse trophectoderm (e4.5).
DESIGN/METHODS: 4 week old female mice were fed a high fat diet (HFD) or control diet (C) for 12 weeks prior to mating. Four days after mating, blastocysts were flushed from uterine horns and trophectoderm
dissected. Trophectoderm from 5 blastocyts was pooled into RNAlater to produce a single sample. Total RNA was isolated and cDNA generated. Samples were hybridized to the GeneChip Mouse Exon 1.0ST array.
Pairwise comparisons were made between groups and false discovery rates (FDR) were calculated along with adjusted p values. The results were filtered with FDR < 0.15 and fold-change > 1.5. Ingenuity Pathway
Analysis (IPA) software was used to evaluate functional pathways.
RESULTS: A HFD significantly altered gene expression in e4.5 trophectoderm (68 genes down-regulated, 175 genes up-regulated) as compared to controls. Ingenuity pathway analysis revealed clustering of these
genes in the processes of mitochondrial function/oxidative phosphorylation (Lyrm4, Ndufaf4, Chchd3, Dlst), epigenetic modifications (Ncoa4, Mettl4, Phf16, Whsc111, Rnf20), cellular invasion (Kif1c, Pik3cb, Capn7),
cell cycle control (Foxj3, Uhmk1, Mobk11b, Uhmk1, Wdr36, Pkn2), cellular proliferation and differentiation (Fgfr2, Mospd1) and lipid metabolism (Asah1, Serinc1,Opa1). Additionally, we observed altered expression of
multiple genes involved in vasculogenesis (Ankrd17, P2ry6, Nkx2-5, Agt, Adra1b).
CONCLUSIONS: Diet induced obesity in the dam alters gene expression pathways in the trophectoderm which are vital to placenta development and necessary to support the developing embryo and fetus. These
alterations may represent one of the many ways in which maternal obesity exerts its effects on the offspring.
Filename: 751886
Presenting Author: Kristina Derrick, MD, MSc
Department/Institution/Address: 3411 Wayne Ave Suite 4M, Bronx, NY, 10467, United States
Phone: 718-920-5612
Fax:
Title: Relationship between Growth Hormone Axis and Pituitary Microadenomas
Kristina Derrick1, Robert Gensure1 and William Gomes2. 1Pediatric Endocrinology, Children's Hospital at Montefiore, Bronx, NY and 2Radiology, Montefiore Medical Center, Bronx, NY.
BACKGROUND: Patients with a diagnosis of short stature (SS)/growth hormone deficiency (GHD) routinely undergo brain MRI prior to starting growth hormone therapy to evaluate for structural abnormality or pituitary
lesion. This screening is performed because, in part, there are suggestions that pituitary microadenomas may be associated with GHD. Conversely, GHD may protect against growth of a microadenoma, and treatment
of these patients with GH may place them at risk for tumor growth.
OBJECTIVE: We investigated the relationship of baseline growth parameters and pituitary microadenomas in pediatric patients with SS/GHD.
DESIGN/METHODS: We performed a retrospective chart review of patients evaluated at our facility with an ICD-9 code for SS (783.43) or GHD (253.3) and who had a brain MRI performed as part of their evaluation
for short stature, in 2000-2013. We reviewed the radiology reports for descriptions consistent with a pituitary microadenoma. We analyzed the baseline IGF-1, IGFBP-3, and peak GH level on stimulation test, when
results were available. We calculated standard deviation scores (SDS) for IGF-1 and IGFBP-3. Association was tested by two-tailed t-test.
RESULTS: We identified 65 patients with microadenoma and 279 without the lesion. Lab results were available in patients with microadenoma for IGF-1 (N=63), IGFBP-3 (N=55), and peak GH (N=55). Among the
patients without the lesion, labs were available for IGF-1 (N=263), IGFBP-3 (N=246), and peak GH (N=232). The SDS for IGF-1 was -1.126 in the microadenoma group and -1.110 in the comparison group (p=0.681).
IGFBP-3 SDS was -0.851 (microadenoma) versus -0.777 (no microadenoma), with p=.676. Peak GH on stimulation test was 6.989 (microadenoma) and 6.991 (no microadenoma), with p=0.997.
CONCLUSIONS: Overall, our retrospective chart review demonstrates that baseline growth hormone parameters are not associated with the presence of a pituitary microadenoma. This suggests that pituitary
microadenomas may not be related to the presence or severity of GHD.
Filename: 755309
Presenting Author: Jason Klein, MD
Department/Institution/Address: 175 Willowood Drive, Wantagh, NY, 11793, United States
Phone: 516-931-1275
Fax: 888-312-5155
Title: Ability of Non-invasive Measurements of Cardiometabolic Health in Predicting Racial Differences in the Metabolic Unhealthy Obese Phenotype
Jason Klein1, Patricia Vuguin1, Christine B. Sethna2 and Ronald Feinstein3. 1Pediatric Endocrinology, Cohen Children's Medical Center of New York, New Hyde Park, NY; 2Pediatric Nephrology, Cohen Children's
Medical Center of New York, New Hyde Park, NY and 3Adolescent Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY.
BACKGROUND: Over the past 30 years, adolescent obesity has exponentially grown, increasing the risk for an ever growing number of diseases, such as hypertension, dyslipidemia, type 2 diabetes, and
cardiovascular disease. While metabolic inflammation is the root cause of obesity-related complications, predicting which obese children are most at risk for complications still remains uncertain. In adults, it has been
shown that endothelial dysfunction predicts these complications and often predates other abnormalities.
OBJECTIVE: We hypothesize that carotid-femoral pulse wave velocity (PWV) is predictive of the cardiometabolic determinants of the Metabolically Unhealthy Obese (MUO) phenotype, independent of BMI.
DESIGN/METHODS: This ongoing cross-sectional case-control study includes active recruitment of obese (BMI >95th percentile) pediatric subjects (aged 10-18 years) at a large, tertiary-care pediatric hospital, along
with age/sex/race matched controls. Anthropometric (height, weight, BMI, abdominal circumference, BP), minimally-invasive (transaminases, glucose, insulin, lipids, uric acid, CRP), and non-invasive cardiometabolic
measurements (PWV) are assessed. Using accepted pediatric guidelines (SBP and/or DBP >90th percentile, total cholesterol ≥200 mg/dL, LDL ≥130 mg/dL, HDL <40 mg/dL, TG ≥150 mg/dL, fasting glucose ≥100
mg/dL, HbA1c ≥6%), patients are categorized as MHO (≤1 factor) or MUO (≥2 factors).
RESULTS: PWV data have been collected on a total of 52 normal-BMI matched controls. A total of 98 obese subjects (M=46, F=52) have been evaluated (preliminary data presented at 2014 ESPR and PAS
conferences). Ongoing data collection (n=34) of serum uric acid and CRP measurements show that MUO subjects tend to have higher values than in MHO subjects for all studied races (Caucasian, African American,
and Hispanic). PWV measurements have been obtained in 4 subjects to date; data collection and analysis is actively ongoing.
CONCLUSIONS: Cardiometabolic risk and the MUO phenotype are independent of BMI and, while racial background remains an important determinant of risk based on conventional labs, elevated serum uric acid
and CRP are predictive in all races. This ongoing study will further look at the predictive abilities of non- and minimally-invasive measurements of cardiometabolic health and MUO phenotype with regards to race, in
particular, comparing PWV between controls, MHO, and MUO subjects.
Filename: 750509
Presenting Author: Daniela E. Purice, MD
Department/Institution/Address: Pediatrics, St. Barnabas Hospital, 4422 3rd Ave,, Bronx, NY, 10457, United States
Phone: 718-960-6635
Fax: 718-960-9418
Is Presenting Author a Trainee? Yes, House Officer
Title: Which Anthropometric Measurements Are the Best Predictors of Metabolic Syndrome in the Pediatric Population?
Daniela E. Purice1, Adriana E. Groisman-Perelstein2,3, Pamela M. Diamantis2,3, Uri Belkind1,2, Paulo Pina1,2 and David H. Rubin1,2. 1Pediatrics, St. Barnabas Hospital, Bronx, NY; 2Pediatrics and Epidemiology, Albert
Einstein College of Medicine, Bronx, NY and 3Pediatrics, Jacobi Medical Center, Bronx, NY.
BACKGROUND: Metabolic syndrome (MSx) is a cluster of interrelated risk factors for type 2 diabetes, cardiovascular disease and fatty liver. Early identification is imperative to facilitate preventative action. For
children age ≥10, MSx can be diagnosed with abdominal obesity (using waist circumference percentiles) and the presence of two or more other clinical features (elevated triglycerides, low HDL-cholesterol, high blood
pressure, increased plasma glucose). Abdominal obesity as a marker of body fat can be conveniently and cost effectively estimated by measuring body mass index (BMI) and waist circumference (WC) and this may
effectively predict the risk of MSx. Other indices of abdominal obesity such as waist height ratio (WHtR) and waist hip ratio (WHR) have also been reported to be better discriminators of metabolic and cardiovascular
risk factors than BMI and/or waist circumference.
OBJECTIVE: Determine which anthropometric measurements are the best predictor of MSx in a pediatric population.
DESIGN/METHODS: We completed a secondary analysis of an NIH prospective study focusing on weight reduction in children, 7-12 years of age with BMI ≥ 85 %ile, in an urban university affiliated community
hospital. Abstracted data included demographic information, measurements of waist circumference (two), height, weight, systolic and diastolic blood pressure as well as laboratory values. Data analysis employed
logistic regression to determine predictors of MSx.
RESULTS: 366 records were reviewed; 51% females, 69.1% hispanic, 19.9% african-american, 3.8% white; age 9.3±1.7 (yrs, mean±SD), BMI %ile 96.4±3.4 (mean±SD). 21.4% of girls and 3.9% of boys were
diagnosed with MSx. BMI %ile, WHR Z-scores, WHtR Z-scores, and BMI Z-scores were independent predictors of MSx, adjusting for gender. WHR Z-score [OR 1.61 ( 95%CI 1.15-2.25)], WHtR Z-score [OR 1.62
(95%CI 1.19-2.2)] and BMI Z-score [OR 2.53 (95% CI 1.14-5.59)] were all significant predictors of MSx when also adjusted for gender.
CONCLUSIONS: These results suggest that specific anthropometric measurements that take into account central adiposity (i.e. WHR, WHtR and BMI) are accurate predictors of metabolic syndrome in obese and
overweight children. These measurements could therefore be safely used as simple, non-invasive screening tools to identify and offer adequate counseling to patients with these characteristics.
Filename: 751728
Presenting Author: Megan Oberle, MD
Department/Institution/Address: Endocrinology, Children's Hospital of Philadelphia, 34th street and Civic Center Boulevard, Philadelphia, PA, 19104, United States
Phone: (216) 536-5905
Fax:
Title: Assessment of IGF-1 Z-Scores in Pre-Pubertal Patients Treated for Growth Hormone Deficiency
Megan Oberle1, Shana McCormack1, Adda Grimberg1 and Vaneeta Bamba1. 1Pediatric Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Assessment of growth hormone (GH) therapy includes monitoring of growth velocity, change in height z-score, and measurement of insulin-like growth factor-1 (IGF-1) concentrations. While height
and growth velocity vary by age, gender, and pubertal status, IGF-1 z-score (IGF-1z) reporting by some clinical laboratories allows for standardized comparison of IGF-1 concentrations. Evidence suggests that GH
dosing targeted to IGF-1z of 0-2SD is safe and may be more dose-</del>sparing than weight-based dosing. There is also evidence for male predominance among referrals for poor growth and U.S. pediatric recipients
of GH therapy. The purpose of this quality improvement (QI) project is to identify frequency of IGF-1z within 0-2SD for GH-treated patients and assess for gender differences.
OBJECTIVE: To assess IGF-1z in pre-pubertal pediatric patients treated for GH deficiency (GHD) at a single center and determine if IGF-1z differs by gender.
DESIGN/METHODS: Retrospective chart review identified 122 GHD patients, of which 48 were excluded due to puberty, missing IGF-1z data, or discontinuation of GH therapy. The most recent on-treatment IGF-1z of
remaining 74 patients were reviewed. Due to large positive skew in the distribution, median IGF-1z was used instead of mean for analyses.
RESULTS: Mean age (+/- SD) at time of evaluation was 6.7 (2.1) years (range 3-9), and 66% were male. Median treatment IGF-1z was 1.5SD, inter-quartile interval (0.4 – 2.6) in females and 1.8 (0.2 – 3) in males,
with no statistical difference detected for gender by Wilcoxon rank sum test. The proportion with IGF-1z in target range (0-2SD) was 44% for females (95% CI, 23–65%) and 42% for males (95% CI, 28-56%), and 40%
of patients had IGF-1z >2. When stratified by gender, there was a negative relationship between age and IGF-1z in females only (Spearman's rho=-0.49, p=0.01).
CONCLUSIONS: Just over half of GHD patients had IGF-1z outside of the target range We did not detect sex-specific differences in overall IGF-1z; in females only, younger age was associated with a higher IGF1z.
Leveraging these initial findings, a detailed investigation of how additional patient- and provider-level characteristics relate to treatment outcomes is ongoing. The potential long-term sequelae of IGF1z outside
physiologic range should also be the focus of future study.
Filename: 751195
Presenting Author: Patrick C. Hanley, MD
Department/Institution/Address: Division of Endocrinology & Diabetes, The Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Suite 1130 NW, Philadelphia, PA, 19104, United States
Phone: 267-331-1127
Fax:
Title: Two Novel Missense Mutations in NPR2 Result in Acromesomelic Dysplasia Maroteaux Type or Impaired Growth: A Family Study with Evidence for an Allelic Dose Effect
Patrick C. Hanley1 and Michael A. Levine1. 1Division of Endocrinology & Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: NPR2 encodes natriuretic peptide receptor B (NPR-B), a transmembrane guanylate cyclase expressed in the growth plate where it enhances skeletal growth. Homozygous loss of function mutations
in the NPR2 gene cause Acromesomelic Dysplasia Maroteaux Type (AMDM), a rare and severe autosomal recessive skeletal dysplasia. Heterozygous NPR2 mutations may be present in 3-6% of patients with
idiopathic short stature.
OBJECTIVE: Describe a non-consanguineous family with AMDM in two siblings, and varying height percentiles in other family members.
DESIGN/METHODS: We analyzed the growth phenotypes of 2 sisters aged 6 and 13 yrs with extreme short stature (height SD less than -3) and generalized brachydactyly and their 3 siblings. Biochemical and
endocrine studies were unrevealing. We performed whole exome sequencing (WES) and confirmed genotypes in all family members by Sanger sequencing.
RESULTS: WES revealed 2 novel missense NPR2 mutations, p.P93S and p.R989L, both in highly conserved residues. In silico analyses predict both changes to be deleterious. The 2 sisters were compound
heterozygotes, consistent with AMDM. The p.P93S allele was maternal (10th percentile for height) and the p.R989L allele was paternal (10th percentile for height). Two other siblings were heterozygotes, a 11-yr old
brother with p.R989L (13% tile) and a 3-yr old sister with p.P93S (26% tile); an 8-yr old brother was wildtype for both alleles (43% tile, MPH of 10% tile). All children were born with length appropriate for gestational
age, and short stature was noted by the end of the first year in the AMDM sisters. The older AMDM sister received growth hormone (GH) from age 8.5 to 12.75 yrs and showed an acceleration in height velocity for 4
years, but appeared at final height to have not gained any additional height. The younger AMDM sister is now receiving GH, with an early increase in height velocity.
CONCLUSIONS: This family demonstrates the influence of NPR2 on growth, and confirms the dose-dependent effect of loss of function alleles on height. Biallelic mutations cause severe phenotypes such as AMDM,
while heterozygous mutations cause a more subtle decrease in height. Our early experience with GH in AMDM shows an early but transient acceleration in growth velocity, but little or no improvement in adult height.
Filename: 751424
Presenting Author: Victor S. Harrison, MD
Department/Institution/Address: Endocrine, Children's Hospital of Philadelphia, 34th adn Civic Blvd, 11NW30, Philadelphia, PA, 19104, United States
Phone: 2673311124
Fax:
Title: Recurrent Pancreatitis in Association with Diabetic Ketoacidosis (DKA)
Victor S. Harrison1 and David Langdon1. 1Endocrine, Childrens Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: We have observed a small cohort of teenagers with known type 1 diabetes (DM1), who are frequently admitted for Acute Pancreatitis (AP), usually in the setting of DKA.
DKA and AP are both associated with abdominal pain; but persistent abdominal pain, surpassing acidosis raises suspicion for AP. However, amylase and lipase are non-specific for AP in the setting of DKA and CT
imaging (the gold standard), which may underestimate early disease, is rarely performed in these children.
The mechanism of pancreatitis in the setting of DKA is unknown. And, although pancreatitis can lead to hyperglycemia and diabetes, it is unknown whether it precedes and causes DKA episodes in these children.
OBJECTIVE: Our objective was to characterize this group and compare them to our average outpatient with DM1.
DESIGN/METHODS: We performed a retrospective review of inpatient admissions, between 2011-2014. We included those who had at least one documented amylase or lipase measurement >3 times the upper limit
of normal. Candidate charts were individually reviewed. A review of literature was done.
RESULTS: We identified 8 teenagers, admitted on average 2.4 times (19 episodes) for pancreatitis +/- DKA. Imaging studies included 1 MRI and 7 Ultrasounds, all but 1 US negative for pancreatitis. Lipase was
positive in all cases but amylase was positive in only 59%.
Cohort (n=8)
Control (n=2186)
Ave Age
14.5 (of 1st episode) 11.7
Male
75%
54%
Caucasian
63%
79%
African American
37%
14%
A1c (stdev)
10.6 (1.9(
8.5 (1.6)
Ave DKA events/yr 1.2
0.12
.
Ave TGLR (n=2): 349 (<165)
Ave AST (n=12): 218 (<35)
Ave ALT (n=12): 125 (<30)
Ave GGT (n=8): 114 (<28)
In our cohort we did not perform any CT imaging, so it is difficult to say how good our biomarkers are at diagnosing pancreatitis. Test characteristics for diagnosing pancreatitis in normal vs. DKA from previous studies
(testing biomarkers to CT imaging) are shown below.
biomarker (>3x ULN) Sensitivity Specificity
Non-Diabetic Adults Lipase
DKA in adults
DKA in children
87
99
Amylase
95
87
Lipase
82
90
Amylase
82
96
Lipase
na
86
Amylase
na
96
CONCLUSIONS: Teenagers with recurrent DKA, elevated A1c, who are of the male sex seem to be at increased risk for developing acute/recurrent pancreatitis.
Clinicians should use amylase, not lipase, to rule out pancreatitis in DKA, as false positive screening tests, increase length of stay and overall costs. Animal studies and prospective clinical trials are needed to clarify
disease mechanisms, and the optimal diagnostic tools.
Filename: 750989
Presenting Author: Lauren A. Kanner, MD
Department/Institution/Address: 265-08 74th Ave, Apt F4, Glen Oaks, NY, 11004, United States
Phone: 224-234-5521
Fax:
Title: New Onset of Asymptomatic Papilledema in Two Growth Hormone Deficient Patients Treated With Recombinant Growth Hormone
Lauren A. Kanner1, Jason Klein1, Howard Pomeranz2, Majida Gaffar2 and Graeme Frank1. 1Division of Pediatric Endocrinology, Cohen Children's Medical Center of New York, Lake Success, NY and 2Department of
Ophthalmology, North Shore-Long Island Jewish Medical Center and Hofstra North Shore LIJ School of Medicine, Great Neck, NY.
BACKGROUND: Growth hormone (GH) therapy is a well recognized risk factor for the development of idiopathic intracranial hypertension (IIH). IIH, also known as pseudotumor cerebri (PTC), is a rare complication of
GH treatment. In the Kabi International Growth Hormone Study (KIGS), the incidence of IIH as an adverse event during recombinant human growth hormone (rhGH) replacement for idiopathic growth hormone
deficiency (GHD) was 13/100,000 treatment years. IIH developed anywhere between 2 weeks to 8 years after initiating GH therapy at a dose of 1.08–0.33 mg/kg/wk. IIH is characterized by elevated intracranial
pressure, papilledema, and symptoms including headache, vision changes, nausea, and vomiting.
OBJECTIVE: To present two patients on recombinant growth hormone who developed isolated asymptomatic papilledema while on treatment.
DESIGN/METHODS: Medical record review of an 11-year-old girl and 5-year-old boy with asymptomatic papilledema without other signs or symptoms of idiopathic intracranial hypertension following GH therapy.
RESULTS: The 11-year-old girl developed papilledema after 6 months of GH treatment with associated visual field loss. She had a negative work-up for papilledema with normal opening pressures on lumbar puncture
and imaging but was diagnosed as IIH. She was treated with oral acetazolamide for 9 months after which the papilledema and visual field deficits resolved . The 5-year-old boy developed papilledema 7 months after
initiation of GH therapy. He also received oral acetazolamide with resolving papilledema on exam 4 months after stopping GH therapy requiring him to continue routine opthalomology follow-up and remain on
acetazolamide treatment.
CONCLUSIONS: Patients on GH replacement therapy are at higher risk not only for symptomatic IIH but also asymptomatic papilledema. This may cause vision loss prior to the development of symptoms of raised
intracranial pressure. These findings suggest that routine ophthalmologic screening of children on recombinant GH replacement therapy is warranted. Given the prolonged resolution of both patients papilledema after
discontuation of GH therapy compared to those who develop IIH which usually resolves within weeks of stopping GH with or without use of medication of the IIH or papilledema itself, investigation also is
recommended to determine if this papilledema is due to a separate etiology than IIH, both related to GH replacement therapy.
Filename: 751269
Presenting Author: Jennifer S. Sarhis, MD
Department/Institution/Address: 265-08 74th Avenue, Apartment F3, Glen Oaks, NY, 11004, United States
Phone: 917-667-6873
Fax:
Is Presenting Author a Trainee? Yes, Other - Resident
Title: Experience With an Interdisciplinary Team To Manage Disorders of Sex Development
Jennifer S. Sarhis1, Phyllis W. Speiser1, Heather L. Appelbaum1 and YeouChing Hsu1. 1Pediatrics, Cohen Children's Medical Center of NY & Hofstra North Shore LIJ School of Medicine, New Hyde Park, NY.
BACKGROUND: Disorders of sex development (DSD) require management by multiple specialties. The Pediatric Urogenital Reproductive & Endocrine Disorders (PURE) Program was established at Cohen Children's
Medical Ctr of NY in March 2013, aiming to provide such patients with comprehensive seamless care.
OBJECTIVE: To compare diagnoses and medical services among patients enrolled in the PURE Program with non-PURE patients & to assess family satisfaction with PURE.
DESIGN/METHODS: The study is IRB approved. Data were collected from all DSD patients 0-18 years seen through PURE 3/2013-10/2014, & from patients with the same diagnostic codes seen outside of PURE in
2012-2014. The number of patients & visits in each category & medical services were tabulated. Simple XY hypospadius cases were excluded. Descriptive statistics were used to compare the two groups.
RESULTS: A total of 69 patients with DSD were seen over a 2.5 year period, evaluated by endocrinology, urology, gynecology, genetics, psychiatry &/or social work. Fourteen patients were enrolled in PURE; families
met with social work, medical & surgical consultants at a single point of care. Of the 14 PURE patients, 10 (72%) had XX DSD, 2 (14%) XY DSD, and 2 (14%) mosaic karyotype; 50% had surgery for genital
reconstruction. Four were newly diagnosed at birth & seen as outpatients by 1 month of age. Sex of rearing was decided for new patients at or prior to the PURE visit. An anonymous survey of legal guardians
revealed that 75% preferred seeing multiple specialists at the same visit. In contrast, 55 similar patients were not enrolled in the PURE program: 29 (52%) had XX DSD, 23 (42%) XY DSD, 2 (4%) mosaic karyotype,
and 1 (2%) XXY DSD; 40% had surgery. In contrast to the experience of PURE program patients, it took an average of nearly 3 months for newly diagnosed cases to secure outpatient appointments with all
specialists. Non-PURE patients were less likely to have encounters with social work, genetic counseling and mental health.
CONCLUSIONS: Patients enrolled in the interdisciplinary PURE program had faster and more comprehensive access to care; families preferred the PURE approach. We anticipate that interdisciplinary programs such
as PURE may facilitate decision making in patients with complex conditions such as DSD.
Filename: 754301
Presenting Author: Jessica Kremen, MD
Department/Institution/Address: 255 Promenade Street, Apt 524, Providence, RI, 02908, United States
Phone: 4018644833
Fax:
Title: Timing of Positive Celiac Disease Serology in Subjects with Type I Diabetes Mellitus
Jessica Kremen1, Lisa Swartz Topor1, Charlotte M. Boney1 and Jose Bernardo Q. Quintos1. 1Pediatrics/Division of Pediatric Endocrinology, Rhode Island Hospital/ The Warren Alpert Medical School of Brown
University, Providence, RI.
BACKGROUND: Celiac disease (CD) occurs in 1-16% of patients with Type 1 Diabetes (T1DM). Serologic screening for CD at diagnosis with T1DM and periodic retesting in patients with poor growth/glycemic control,
or gastrointestinal symptoms is recommended. Anecdotal evidence indicates that screening practices vary widely and data on optimal timing of repeat screening is limited.
OBJECTIVE: To describe the prevalence of positive CD screening serology and biopsy-confirmed CD at diagnosis with T1DM and timing of subsequent positive CD serology and disease in subjects with negative
initial CD serology.
DESIGN/METHODS: We retrospectively reviewed the medical records of subjects diagnosed with T1DM from 2003-2008, seen annually in our clinic for at least 4 years after diagnosis. Inclusion criteria: 1) Initial CD
screening at or within 1 year of diagnosis with T1DM and 2) normal IgA level or IgG-based CD serology. We defined positive CD serology as tissue transglutaminase IgA>20 units, endomysial antibody IgA>1:5 or
antigliadin IgG or IgA>20. We defined biopsy-confirmed CD as positive serology and intestinal biopsy consistent with CD per modified Marsh criteria. We obtained data on timing and outcome of CD screening and
intestinal biopsy.
RESULTS: Six (3.5%) of the 171 subjects had biopsy-confirmed CD. Of the 12 subjects with positive CD serology at initial screening, 8 underwent intestinal biopsy, 6 of whom had biopsy-confirmed CD. Of the 5
subjects with initially negative CD serology who developed positive CD serology 1-2 years after T1DM diagnosis, 2 underwent biopsy (1 confirmed CD, 1 equivocal.) Of the 3 subjects with initially negative CD serology
who developed positive CD serology 2-4 years after diagnosis, 1 underwent biopsy, which was negative. Nine of 10 subjects with positive serology without biopsy had normalization of serology on subsequent testing.
CONCLUSIONS: Prevalence of CD is lower in our population as compared to prior reports of CD in T1DM. All subjects with biopsy-confirmed CD had positive TTG on initial screening. Our study suggests that the
highest yield of identifying biopsy proven CD occurs in the first 2 years of diagnosis of T1DM. We suggest annual routine serologic testing for CD the first 2 years after T1DM diagnosis.
Filename: 752913
Presenting Author: Kristina Malik, MD
Department/Institution/Address: Pediatrics, Baystate Medical Center, 759 Chestnut St, Springfield, MA, 01199, United States
Phone: 4137940000
Fax:
Title: Impact of Distance To Care on Management of Childhood Type 1 Diabetes
Kristina Malik1, Jane Garb2 and Holley Allen1. 1Pediatrics, Baystate Childen's Hospital, Springfield, MA and 2Academic Affairs, Baystate Medical Center, Springfield, MA.
BACKGROUND: Childhood T1DM management is often complicated by social and demographic factors that impact self-care. While literature on the adult chronic disease population has shown that perceived access
to care and rurality are both factors related to poorer outcomes, this area has not been well studied in the pediatric population. Children may be less likely to receive recommended care based on distance to care
center.
OBJECTIVE: To determine if glycemic control (A1c) and obtaining recommended care is associated with distance to care (i.e. distance to the regional pediatric endocrinology office from a patient's home).
DESIGN/METHODS: We performed a chart review of patients with T1DM at our primary center during a 2 year period. We are located in an urban city in western MA. A Geographic Information System (GIS) was
used to determine Euclidian distance from the patient's home to the clinic. Association of distance to care for patients within 25 miles and selected clinical outcomes was assessed using linear regression or the
Student's T-test.
RESULTS: Our population consisted of 290 subjects with T1DM with a mean (±SD) age of 16.6 years (±3.1). The mean duration since diagnosis was 6.5 years (±3.3). The mean number of visits in the 2 year period
was 6.4. The population had a mean A1c of 8.5% (±1.6). The majority of patients (77%) lived within 25 miles of care. Closer distance was positively associated with number of visits (p=0.016). Patients on the pump
(36%) lived significantly further than those off-pump (8.4 vs 5.3 miles, p << 0.0001). Distance was marginally associated with number of A1c's obtained (p=0.06). HbA1c was not associated with distance to diabetes
center.
CONCLUSIONS: Patients living closer to the primary pediatric endocrine office attended more office visits but were less likely to use insulin pump. Glycemic control was not associated with distance to care. Distance
to care has impacts on management of T1DM and being mindful of a patient's access to care may improve patient outcomes.
Filename: 754792
Presenting Author: Sani M. Roy, MD
Department/Institution/Address: 633 W. Rittenhouse St., Apartment A1115, Philadelphia, PA, 19144, United States
Phone: 214-868-2752
Fax:
Title: Concordance Between Weight-for-Length (WFL) and BMI Under Age 2 Years in a Large, Longitudinal, Multi-Ethnic Cohort
Sani M. Roy1, Jordan G. Spivack1, Myles S. Faith2, Alessandra Chesi1, Jonathan A. Mitchell1, Struan F.A. Grant1, Babette S. Zemel1 and Shana E. McCormack1. 1The Children's Hospital of Philadelphia, Philadelphia,
PA and 2University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC.
BACKGROUND: There is no consensus on how to measure adiposity in children under age 2 years. WFL curves are often used but do not reflect age-dependent patterns of infant growth. No studies have compared
WFL & BMI Z-scores in infancy.
OBJECTIVE: To compare WFL and BMI Z-scores in infancy & identify characteristics associated with discordance between these measures.
DESIGN/METHODS: Growth data were extracted from electronic medical records for 73,949 healthy, full-term infants, ages 0-24mo, from the CHOP pediatric care network. WHO WFL & BMI Z-scores were calculated
from well-child checks, & correlation analysis was performed for each age group. WFL & BMI percentiles were classified as: underweight (<5%ile), normal weight (5-85%ile), overweight (85-97.7%ile), & obese
(>97.7%ile); measurements were “concordant” if the percentile category was the same & “discordant” if different. Bivariate analyses were performed to assess effects of age category (> or <6 months), sex, population
ancestry, Medicaid status, length & weight Z-score categories (by chi-square) on discordance status. T-tests assessed difference in BMI Z-score at age 2yr by concordance status at age 2mo.
RESULTS: Using346,939 simultaneous length & weight measurements, correlations between WFL Z-scores & BMI Z-scores increased from r=0.88 at birth (p<0.001) to r=1.0 at 6mo (p<0.001) & remained strong
(r=0.98-0.99) from 6-24mo (p<0.001). Overall, 10% of WFL & BMI measurements were discordant; 14% were discordant below & 6% discordant above age 6mo. Bivariate analysis demonstrated more discordance
than expected in males (p<0.001), non-Hispanic Blacks (p<0.001), age <6mo (p<0.001), Medicaid status (p<0.001), and extremes of length & weight Z-scores at >97.7%ile or <5%ile (p<0.001 for both). Those
discordant at age 2mo had significantly higher BMI Z-score at age 2yr than subjects with concordant measures (Z=0.65 vs. Z=0.45, p<0.001).
CONCLUSIONS: Concordance between WFL and BMI Z-score increased from birth to 6mo & remained consistently high thereafter. Discordance of WFL & BMI Z-score was associated with clinical factors and, in
early infancy, was related to higher risk of obesity in early childhood. Analyses are ongoing with a view to developing evidence-based guidance for clinicians on how best to use anthropometrics to counsel regarding
infants' future risk for obesity.
Filename: 753957
Presenting Author: Dayanand N. Bagdure, MBBS MPH
Department/Institution/Address: Department of Pediatrics, Univerisity of Maryland, 110 S Paca Street, 8th Floor, Baltimore, MD, 21201, United States
Phone: 0017865430577
Fax:
Title: Burden of Encephalitis in the Pediatric Intensive Care Units in United States
Dayanand N. Bagdure1, Jason W. Custer1, Brandon W. Beam2 and Adnan Bhutta1. 1Pediatrics, University of Maryland, Baltimore, MD and 2Informatics, Arkansas Children's Hospital, Little Rock, AR.
BACKGROUND: Encephalitis can lead to significant morbidity and mortality in children. Resource utilization for children with encephalitis in the Pediatric Intensive Care unit (PICU) is unknown.
OBJECTIVE: To describe diagnostic and therapeutic interventions in children with encephalitis in the PICUs across United State.
DESIGN/METHODS: Data for this study was obtained from Pediatric Health Information System (PHIS), a national database with information from 40 pediatric hospitals. Over a period of 2004-2013 we identified 3289
children with encephalitis requiring ICU services. Descriptive analysis was performed on this large dataset.
RESULTS: Median age of the cohort was 9.1 years, males comprising 53% of the cohort. Most common procedure was a lumbar puncture (60%) and cerebrospinal fluid cultures were analyzed in 50% of the cohort.
30% (967) children had seizures during their hospitalization and the most common anti epileptics were fosphenytoin (39%) and levetiracetam (36%). Vancomycin (57%) and acyclovir (51%) were the most frequently
used anti-microbials. 1681 (51%) children required mechanical ventilation with average ventilator days being 5.8 days. Methylprednisolone (43%) and intravenous immunoglobulin (23%) children received
anti-inflammatory agents. 6% of the cohort received plasmapheresis during their hospital stay. 211 (6.4%) children died in the hospital indicating a high mortality for this cohort.
CONCLUSIONS: The burden of encephalitis in children is substantial with considerable morbidity and mortality.Studies looking at the risk factors for morbidity and mortality in children with encephalitis are necessary.
Filename: 753790
Presenting Author: D. Aboudi, BA
Department/Institution/Address: Pediatrics, The Regional NICU, Maria Fareri Children's Hospital, Westchester Medic, 100 Woods Rd, Valhalla, NY, 10595, United States
Phone: (914)715-4139
Fax:
Is Presenting Author a Trainee? Yes, Other - MPH Candidate
Title: Earlier Transfer of Very Preterm Neonates to a Regional Perinatal Center Is Associated with Improved Outcomes
D. Aboudi1, S. Shah1 and H.L. Brumberg1. 1Pediatrics, The Regional NICU, Maria Fareri Children's Hospital, Westchester Medical Center - NYMC, Valhalla, NY.
BACKGROUND: Neonatal transport is a necessary consequence of regionalized care and is associated with improved short term survival. However, in very premature infants, the effects of the timing of neonatal
transport and survival without morbidities have not been thoroughly explored.
OBJECTIVE: To examine the relationship between level of neonatal referral (from Level I, II, III to a regional perinatal center, RPC, Level IV) and age at transport (in hrs) to Neurologic Survival (absence of Grade III or
IV intraventricular hemorrhage or periventricular leukomalacia) and Intact Survival (neurologic survival plus absence of severe retinopathy of prematurity, ROP, and bronchopulmonary dysplasia, BPD).
DESIGN/METHODS: Demographic data were extracted from the NY State Perinatal Data System and compared with age at transport for infants between 23-30wks gestational age (GA) from 2006-2013 admitted to
the RPC. Transport time was divided into categories: 0-6, >6-24 and >24hrs of life. BPD was defined as respiratory support at 36wks post-conceptional age (PCA). Those discharged at <36wks PCA were excluded
from BPD analyses. ROP was defined as stage ≥3 disease or plus disease. Analysis used chi-square, Fisher's Exact Test, T-test, ANOVA and Test of Trend. A p<0.05 was significant.
RESULTS: Of 1,111 eligible infants, 252 (22.7%) were transported to the RPC at a mean (±Standard Deviation) GA and birth weight (BW) of 26.5±2wks and 964±292gm, respectively. 105 (41.7%) were transported at
<6hrs, 51 (20.2%) at 6-24hrs and 96 (38.1%) >24hrs. Groups did not differ by GA or BW. Patients transferred >24hrs originated primarily from Level III care (86%).
Test of trends showed earlier transfers had significantly higher rates of both Neurologic Survival (78%, 71%, 66% at 0-6, >6-24, >24hrs, respectively [N=252]) and Intact Survival (43%, 28%, 15% at 0-6, >6-24, and
>24hrs, respectively [N=172]). No relation between time of transfer and mortality was observed. Lower level of referral hospital was associated with higher Intact Survival (42%, 38%, 16% at level I, II, III, respectively
[N=172]), but not with Neurologic Survival.
CONCLUSIONS: Earlier transfer to an RPC is associated with improved neurologic and overall intact survival, but not mortality. Rapid determination of the need for higher level of neonatal care may improve
outcomes.
Filename: 753045
Presenting Author: Jana Shaw, MD,MPH
Department/Institution/Address: 750 E Adams Street, Syracuse, NY, United States
Phone: 3154647235
Fax:
Title: Impact of Religious Affiliation and School Tuition on Non-Medical Immunization Exemptions (NME) in Private Schools in California
Jana Shaw3, Cristina Desemone1, Robert Bednarczyk2, Jessica Nadeau1, Erica DeNicola1 and Louise-Anne McNutt1. 1University at Albany, Albany, NY; 2Emory University, Atlanta, GA and 3SUNY Upstate Medical
University, Syracuse, NY.
BACKGROUND: Private schools have a higher proportion of NME than public schools. The relative importance of religious beliefs and affluence remains unclear.
OBJECTIVE: The purpose of this study was to determine if school tuition, a surrogate for parental socio-economic status (SES), was associated with NME among California private school kindergarteners.
DESIGN/METHODS: The number of kindergarteners with NME in 2012-2013 school years was obtained for randomly selected CA private schools. NME rates were calculated as the percent of children with NMEs
among kindekarteners by school. The association between tuition and the proportion of NMEs was assessed using χ2 test.
RESULTS: Of the 1969 private schools, we included a random sample of 522 schools. Overall the proportion of NME increased with tuition (p<0.0001). Similar trend was observed regardless of private school type,see
figure 1.
Higher tuition was associated with lower “Up-to-Date” immunization status (p<0.0001), and a lower immunization coverage for each vaccine (p<0.001),see figure 2.
CONCLUSIONS: We found a strong association between school tuition and NME regardless of religious affiliation. Our study suggests that parental SES may play a larger role in vaccine refusal decisions than
underlying belief structures. Future studies are needed to explore the relationship between SES and reasons for seeking exemptions at the individual level.
Filename: 755914
Presenting Author: Xiaobin Wang, MD, MPH, ScD
Department/Institution/Address: Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe street, Baltimore, MD, 21205, United States
Phone: 4109555824
Fax:
Title: Maternal Folate Levels and Child's Metabolic Biomarkers At Birth and in Childhood
Guoying Wang1, Tina L. Cheng2, Kamila Mistry2, Barry Zuckerman3 and Xiaobin Wang1. 1Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; 2Johns Hopkins University School of Medicine,
Baltimore, MD and 3Boston University School of Medicine and Boston Medical Center, Boston, MD.
BACKGROUND: The role of folate in preventing neural-tube defects has been well-established. However, findings regarding long-term effects of maternal folic acid supplementation and plasma folate levels on
offspring's metabolic outcomes remain limited.
OBJECTIVE: To investigate the association between maternal self-reported folic acid intake and peripartum plasma folate level with metabolic biomarkers (measured at birth and in childhood).
DESIGN/METHODS: This report includes a total of 2057 mothers with singleton live births, who were recruited from 1999-2012 and followed prospectively from birth to 2012, as part of the Boston Birth Cohort (BBC).
Mother's plasma folate and B12 levels were measured 2-3 days postpartum and they were asked about their multivitamin use (preconception and 1st-3rd trimester). Leptin, insulin, and adiponectin was measured in a
subsample (n=1225) of the BBC children at birth and in childhood (mean age of 2.7 y).
RESULTS: There is considerable variability in plasma folate levels (GM= 27.7, IQR: 18.9-41.3 nmol/L) among the study mothers. Folate levels were positively associated with gestational age and birthweight,
independent of maternal vitamin B12 levels and other important covariates. Compared with the lowest folate quartile, the highest quartile was associated with 30% lower risk of preterm birth (OR=0.7, 95%CI: 0.5-0.9);
and a 32% (95%CI: 15% to 50%) reduction in insulin/leptin ratio (a surrogate of insulin resistance) at birth. In childhood, the highest maternal folate quartile was associated with 18% (5 to 31%) reduction in plasma
insulin ( a proxy of insulin resistance) and 1.39-fold (1.06-1.72) increase in adiponectin/leptin ratio (a proxy of insulin sensitivity), compared to the lowest quartile; the associations remained significant after adjustment
for key covariates.
CONCLUSIONS: There was abeneficial effect of maternal folate levels on offspring's gestational age, birthweight, and metabolic biomarkers at birth and in childhood. The findings underscore that folate is not only
important for improving birth outcomes, but maybe beneficial for reducing offspring's future risk of metabolic abnormalities.
Filename: 756143
Presenting Author: Xiaobin Wang
Department/Institution/Address: Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe street, Baltimore, MD, 21205, United States
Phone: 312-4978025
Fax:
Title: Self-Reported Folic Acid Intake and Plasma Folate Levels in a Sample of Urban Low-Income Mothers
Guoying Wang, Tina L. Cheng, Kamila Mistry, Barry Zuckerman and Xiaobin Wang. 1Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 2Johns Hopkins School of Medicine, Baltimore, MD and 3Boston
University School of Medicine, Boston, MA.
BACKGROUND: In the US, folic acid supplementation for all women of childbearing age and universal folic acid fortification has greatly reduced the incidence of neural-tube defects. Prior work raised concerns that
Hispanic women had lower folic acid intake and higher rates of neural tube defects than non-Hispanic white women; however, the sample included women of reproductive age, but not specifically pregnant mothers.
OBJECTIVE: To examine racial/ethnic differences in folic acid intake and plasma folate levels in a diverse sample of U.S. urban mothers.
DESIGN/METHODS: This report includes 2,057 low-income mothers with singleton live births (1541 black, 282 Hispanic, 80 white, and 154 others) aged 16-51 years enrolled in the Boston Birth Cohort from
1999-2012. Mothers were asked frequency they took multivitamins during preconception and 1st-3rd trimester and their plasma folate levels were measured.
RESULTS: The percentage of women taking vitamins at least once/week during - preconception, 1st, 2nd and 3rd trimester were 4.3%, 89.3%, 94.5%, and 92.8%, respectively. Compared to white mothers, black and
Hispanic mothers had lower intake across the 4 time periods. Consistently, black mothers had the lowest geometric mean folate level: 26.8 nmol/L (95% CI: 26.0-27.6), followed by Hispanic mothers: 29.0 (27.1-31.0),
compared to white mothers: 34.1(30.2-38.6). Multiple regression revealed that lower plasma folate levels were associated with black or Hispanic race, greater parity, and cigarette smoking. Higher frequency of
maternal multivitamin intake in the 3rd trimester was associated with higher plasma folate levels at peripartum.
CONCLUSIONS: In this sample of urban, low-income mothers, preconception multivitamin intake was very low among all racial/ethnic groups. Black and Hispanic mothers had lower frequency of intake and lower
plasma folate levels than white mothers. The study findings underscore the need to improve preconception multivitamin intake for all women of childbearing age with particular attention to black and Hispanic women.
Filename: 755243
Presenting Author: Kathleen A. Abreo
Department/Institution/Address: Pediatric Outcomes Research Team (PORT), The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
Phone: 4165283511
Fax:
Is Presenting Author a Trainee? Yes, Undergraduate Student
Title: Objectively Measuring Physical Activity in Early Childhood Using Accelerometers: Are 4 Days Enough?
Kathleen A. Abreo1, Cornelia M. Borkhoff1,2, Laura N. Anderson1,3, Hrishov Sarker4, Jonathon L. Maguire1,2,3,5,6, Patricia C. Parkin1,2,6 and Catherine S. Birken1,2,6. 1Pediatric Outcomes Research Team (PORT), Division
of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada; 2Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; 3The
Applied Health Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; 4Department of Epidemiology, Biostatistics, and Occupational Health,
McGill University, Montreal, QC, Canada; 5Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada and 6Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
BACKGROUND: Studies of physical activity (PA) in young children have generally included only participants with at least 4 days of accelerometer wear-time. It is unclear whether 4 days characterizes usual PA in
children 5 years and under. Investigating this protocol may inform future studies of early childhood obesity.
OBJECTIVE: To determine the minimal number of days, and what days, of accelerometer monitoring are needed to reliably estimate usual PA in young children.
DESIGN/METHODS: Ninety children (mean age=32 (range, 4-70) months) were instructed to wear an Actical accelerometer for 7 consecutive days and had at least 4 valid days. Intraclass correlation coefficients
(ICC) and 95% CI were calculated for mean daily total PA and moderate-to-vigorous PA (MVPA) minutes derived from 4 days of monitoring. The Spearman-Brown prophecy formula was used to determine the
required days of monitoring needed to achieve reliability estimates of 0.70, 0.80, and 0.90.
RESULTS: A single day produced a reliability of ICC=0.70 (95%CI:0.58-0.79) and ICC=0.69 (95%CI:0.57-0.79) for total PA and MVPA, respectively. Spearman-Brown analyses indicated that 2 days are needed to
achieve a reliability of 0.80. There were no differences between weekdays and weekend days in mean total PA (205 (95%CI:187-222) vs. 210 (95%CI:192-228); p=0.70) or in mean MVPA minutes 26 (95%CI:20-32)
vs. 29 (95%CI:23-36); p=0.45).
CONCLUSIONS: Any two weekdays or weekend days of accelerometer monitoring can be used to assess usual PA in children 5 years and under. The use of a simpler protocol may improve compliance and feasibility
for studies of PA in early childhood.
Filename: 750373
Presenting Author: Kshiti D. Shah, MD
Department/Institution/Address: Pediatrics, Christiana Care Health System, 4745 Ogletown Stanton Roads, MAP-1, Suite 217, Newark, DE, 19713, United States
Phone: 302-733-2410
Fax: 302-733-2602
Title: Contribution of Birth Defects as a Cause of Fetal and Infant Deaths in Delaware
Kshiti D. Shah1, Dana Thompson1, Kathleen Stomieroski1, Amy Acheson1, Deborah B. Ehrenthal4, Russell S. Kirby3, Louis Bartoshesky1 and Robert Locke1,2. 1Neonatology/Womens and Infants Research, Christiana
Care Health System, Newark, DE; 2Pediatrics, Jefferson Medical College, Philadelphia, PA; 3Community and Family Health, Univ of South Florida, Tampa, FL and 4Obstetrics and Gynecology and Population Health
Sciences, University of Wisconsin-Madison, Madison, WI.
BACKGROUND: The accuracy of classification of fetal and infant deaths can play a significant role in health policy and in determining appropriate interventions to improve survival.
OBJECTIVE: To determine the contribution of birth defects to fetal and infant mortality rates in Delaware 2007-2010.
DESIGN/METHODS: De-identified 2007-2010 data from the Delaware Birth Defects Registry (DBDR), was reviewed by team members (neonatologist, geneticist, birth defects experts) to determine if the death of each
fetus or infant was due to the birth defect or due to another cause. DBDR data is chart extracted and reviewed to confirm accuracy. Cases where the cause of death could not be determined between birth defect and
prematurity were considered "arguable," while cases in which the cause of death was determined to be neither a birth defect or prematurity were labeled "other."
RESULTS: Between 2007-2010, there were 574 fetal-infant total deaths with 107 (18.6%) deaths with a birth defect. 76 deaths (71.0% of fetus-infant with a birth defect or 13.2% of total deaths) were primarily due to
the birth defect. 7 deaths (6.5% of DBRB or 1.2% of total deaths) were due to neither birth defect or prematurity. 17 deaths (15.9% of DBRB or 3.0% of total deaths) were considered arguable on the primary cause of
death being a birth defect or prematurity. The total number of deaths attributed to a birth defect (unequivocally or arguably) ranged from 13.2 to 16.2 of total fetal-infant deaths.
CONCLUSIONS: Birth defects are a minority cause, 13.2%-16.2%, of fetal-infant mortality in Delaware. Other causes (ex. prematurity, maternal health) are responsible for the majority of fetal and infant deaths.
Among infants with a birth defect and prematurity, the cause of death was uncertain in small fraction (3% of total fetal-infant deaths). This uncertainty (prematurity vs birth defect) has a minimal impact within the overall
attributable death rate for birth defects. Since the data was obtained by chart review, not Vital Statistics, the accuracy of these findings is high. This knowledge can affect health policy and the appropriate allocation of
resources of efforts to improve pregnancy and infant health outcomes.
Filename: 751815
Presenting Author: Stacey Kallem, MD
Department/Institution/Address: 2020 Walnut St, Apt 5K, Philadelphia, PA, 19103, United States
Phone: 650-704-8440
Fax:
Title: Floorientations: An Intervention To Improve Intern Preparation for Inpatient Subspecialty Units
Stacey Kallem1, Hareem Park1, Joelle Karlik2 and Andrew Palladino1. 1Children's Hospital of Philadelphia, Philadelphia, PA and 2Oregon Health & Sciences University, Portland, OR.
BACKGROUND: Intern year of Pediatric residency training at a children's hospital includes new exposures and frequent transitions to subspecialty services. A successful transition requires a basic understanding of
the medicine involved and knowledge of the service-specific protocols. Orientations are often attempted early in a rotation, however, given the high volume and rapid turnover, are inconsistent in timing and content.
OBJECTIVE: To determine if providing pre-created, floor-specific, orientation powerpoints, or “floorientations,” would increase the likelihood of Interns receiving an orientation as well as increase their perceived
preparedness for the rotation.
DESIGN/METHODS: Powerpoint presentations were created for each subspecialty Intern service under the guidance of subspecialty Attendings. The presentations were given uniformly in a 30 minute time frame on
the 3rd morning of each rotation. They were presented by senior Residents on the team, with support from Attendings, Fellows, nurses, case managers, and social workers. Surveys were completed pre- and
post-implementation of floorientations. All data were analyzed using SPSS and Chi-square analysis was used to determine statistical significance.
RESULTS: 48 surveys have been completed to date. Prior to the implementation of floorientations, 40% of Interns reported receiving an orientation, compared to 73% who received an orientation post-implementation.
58% of those who received a floorientation reported having a better understanding of specialty-specific medical equipment compared to 13% of those who did not receive a floorientation (p <0.05). 65% of those who
received a floorientation reported feeling more comfortable with unit-specific nursing concerns compared to 29% of those who did not (p <0.05). Finally, there was a trend that receiving a floorientation increased
Interns' knowledge of specialty-specific electronic medical record shortcuts (p =0.06).
CONCLUSIONS: The use of pre-created, floor-specific, orientation presentations increases the likelihood that orientation to subspecialty services will occur. Moreover, the introduction of these orientations increases
an Intern's understanding of specialty-specific medical equipment and nursing concerns. Further investigation is needed to assess whether this increased sense of preparedness will ultimately result in improved
patient safety and care.
Filename: 750630
Presenting Author: Carol Lynn O'Dea, MD
Department/Institution/Address: PO Box 6037, Lawrenceville, NJ, 08648, United States
Phone: 609-529-9926
Fax:
Title: Evaluation of Prioritization Skills in Neonatology Fellowship Trainees
Carol Lynn O'Dea1, Scott A. Lorch2, Mark X. Cicero3, Newton Buchanan1, Roberta L. Hales1 and Heather M. French2. 1Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; 2Pediatrics, University of
Pennsylvania, Philadelphia, PA and 3Pediatrics, Yale University, New Haven, CT.
BACKGROUND: Clinical prioritization is vital to managing multiple complex patients in the NICU. Neonatology trainees enter fellowship with varying levels of autonomy, procedural and clinical decision-making skills
and there is no clear method of teaching or measuring these skills. To date, there are no studies investigating the development of clinical prioritization in trainees.
OBJECTIVE: The study objectives are to 1) investigate if prioritization skills differ in neonatology trainees compared to academic attending neonatologists and 2) investigate whether prioritization skills differ in a
time-unlimited versus a time-limited setting.
DESIGN/METHODS: Six 8-item surveys of common NICU scenarios were developed. Twenty academic neonatologists (experts) determined the prioritization order of the scenarios via a Delphi method. Two surveys
were sent to neonatology trainees nationally. Surveys were divided into priority tertiles based on “expert” rank. The rankings of the 1st-tertile scenarios were summed. Scores ranged from 6 (expert) to 21. Mean scores
analyzed by 2-sided t-test and ANOVA assessed differences in prioritization between fellows and the “experts.”
A multi-patient simulation was created to simulate a NICU experience. Fellows were instructed to assess the patients in the order of perceived importance. The simulation was followed by completion of a survey of
prioritization rankings. Fellows received a 1st-tertile score in the simulation and in a post-simulation survey. Mean scores were analyzed by a 2-sided t-test followed by ANOVA.
RESULTS: In a time-unlimited environment, there was a significant difference in 1st-tertile scores among all years of training compared to the experts (p<0.05). There was no difference between fellowship years and
no evidence of improvement in scores with increased experience. In a time-limited environment, there was a significant difference in scores among some years of training compared to the experts (p<0.05).
CONCLUSIONS: Prioritization skills of neonatology fellows do not reach an “expert” level in a time-unlimited or time-limited environment. These findings may be due to clinical knowledge, clinical decision-making or
prioritization experience both prior to and during fellowship. The gap in prioritization skills suggests that neonatology fellowship education should include dedicated teaching of prioritization and clinical decision-making
skills.
Filename: 752142
Presenting Author: Sarah Varghese, MD
Department/Institution/Address: Department of Pediatrics, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY, 10305, United States
Phone: 718-813-4700
Fax:
Title: Pediatric Research and Scholarship Committee: A Single Institution Initiative To Enhance Scholarly Activity of Pediatric Residents
Sarah Varghese1, Juae Cynthia Chang1, Sarah Vaiselbuh1, Ljumnije Demirovic1, Richard Sidlow1, Jonathan Blau1 and Eleny Romanos-Sirakis1. 1Department of Pediatrics, Staten Island University Hospital, Staten
Island, NY.
BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires residents to participate in scholarly activity during their training period. Programs define and achieve this goal through
varied guidelines. We describe an initiative put forth at our institution to promote scholarly activity of pediatric residents.
OBJECTIVE: We sought to improve scholarly activity of pediatric residents by providing residents with support and guidance from a committee of faculty and staff members dedicated to advancing research within the
program. We subsequently measured change in scholarly productivity of residents after the development of this Pediatric Research and Scholarship Committee (PRSC).
DESIGN/METHODS: The PRSC (established in 2012) ascertained research interests of pediatric residents and matched residents with research mentors based on mutual interests and goals. The PRSC met regularly
to discuss the progress of the residents' scholarly activities and served as liaisons between residents, faculty and the Institutional Review Board (IRB). During the initial phases of their projects, residents gave platform
presentations on their scholarly activities to the PRSC faculty as well as their peers. This provided a forum for improvement of public speaking and feedback to each individual resident project.Interested residents were
encouraged to submit their work for presentation at conferences, with a further goal of creating a manuscript for publication.
RESULTS: In the two academic years prior to the creation of the PRSC, 3/16 residents (19%) gave a total of three oral and/or poster presentations at regional/national conferences. During the two years following the
implementation of the PRSC, 10/32 residents (31%) gave a total of twenty-one presentations. The proportion of residents with at least one abstract accepted for presentation post-PRSC increased by 67% compared
to pre-PRSC and we anticipate further improvements with continued mentorship. In addition, three papers were published with a resident as first author post-PRSC.
CONCLUSIONS: Implementation of a research committee comprised of dedicated faculty and administrative staff can play a vital role in stimulating productivity in resident research and scholarly activity. Our model
can be adapted by other residency programs seeking to advance resident scholarly activities.
Filename: 752645
Presenting Author: Stephanie Buhlig, MD
Department/Institution/Address: National Capitol Consortium Pediatric Residency, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, United States
Phone: 301-295-4900
Fax: 301-295-6173
Title: Comparing Peer and Staff Evaluations of Pediatric Residents Using the ACGME Milestones
Stephanie Buhlig1, Jennifer Hepps1 and Gregory Gorman1. 1National Capitol Consortium Pediatric Residency, Walter Reed National Military Medical Center, Bethesda, MD.
BACKGROUND: The optimal method of evaluating residents using ACGME Pediatric Milestones is unclear. Although staff evaluations from Clinical Competency Committees (CCC) are the gold standard, peer
evaluations provide unique information in trainee assessment.
OBJECTIVE: To assess agreement between resident peer evaluation and Clinical Competency Committees
DESIGN/METHODS: Thirty-three residents were asked to evalaute on their fellow trainees. The evaluation was comprised of 28 anchor phrases that correspond to 11 sub-competencies of the ACGME Pediatric
Milestone Project. Residents were asked to rate their peer on a 5-point Likert scale for each anchor. The CCC evaluated each resident on a 9-point 1-5 Likert scale. Peer evaluations were de-identified and tagged to
their staff evaluation. Means from the peer evaluations for each sub-competency were rounded to the nearest 0.5 increment on a 9 point scale. Pearson's correlation coefficients were used to assess for agreement.
Paired t-tests were calculated to determine mean differences between evaluations.
RESULTS: Nineteen residents completed evaluations on 14 peers. Correlation coefficients for each sub-competency ranged from poor (PR1 = 0.19) to very good (ICS2 = 0.88).
Competency
Sub-Competency
Correlation Coefficient
PC1: Gathers essential & accurate information about patients
0.63
PC2: Can organize and prioritize patient care responsibilities
0.67
PC3: Gives high quality hand-overs
0.55
PC5: Skilled at physical exam techniques and recognizes subtle findings
0.44
PBLI1: Self aware of own knowledge and skill limitations
0.50
ICS1: Communicates effectively with patients
0.66
ICS2: Recognizes and anticipates social cues in interpersonal interactions
0.88
PR1: Compassionate
0.19
PR4: Sets high standards of professional and ethical behavior
0.79
SBP2: Coordinates patient care well
0.25
SBP3: Considers cost when making clinical decisions
0.50
Patient Care
Practice Based Learning & Improvement
Interpersonal & Communication Skills
Professionalism
Systems-Based Practice
Peer evaluations had overall higher mean scores than the CCC (mean difference 2.39, 95% CI 2.22 – 2.57).
CONCLUSIONS: Peer evaluation of residents provides useful assessment of milestones. Peer assessment of sub-competencies in interpersonal communication and professional behavior correlate best with CCC.
Sub-competencies that assess patient care and physical exam skills correlate poorly. Residents assess the competence of their peers higher than CCC assessment.
Filename: 752665
Presenting Author: Allison Gault, MD
Department/Institution/Address: Medical Education and Pediatrics, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY, 10029, United States
Phone: 212-241-7207
Fax: 212-996-9685
Title: Mentorship and Longitudinal Integrated Clerkships: A Pilot Study
Allison Gault1, Robert Fallar2, Cinthia Delarosa2, Yasmin Meah3 and David Thomas3. 1Pediatrics and Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY; 2Medical Education, Icahn School of
Medicine at Mount Sinai, New York, NY and 3Medicine and Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY.
BACKGROUND: Traditional medical education places 3rd and 4th year students in discipline-specific blocks with limited longitudinal contact with faculty members. In contrast, longitudinal integrated clerkships (LICs)
provide an innovative model in which 3rd year students are paired 1:1 with faculty throughout the academic year, cementing a robust mentoring relationship. It is unclear, however, whether LIC students perceive
improved mentorship experiences when compared to students on traditional tracks (TT).
OBJECTIVE: To compare mentorship experiences in one medical school between LIC students and TT students.
DESIGN/METHODS: A 65 item Likert-scale survey was designed based on mentorship themes identified in the literature and pilot tested prior to its administration. The survey was sent electronically to a total of 297
students from 2 consecutive 4th year medical student classes at the Icahn School of Medicine at Mount Sinai (ISMMS) during July-September 2013 and July-September 2014. Survey responses were analyzed using
Fisher's exact test.
RESULTS: The overall response rate was 27% with 83 students responding to the survey. Respondents were 36% male and 64% female. Of those who responded, 70 identified a mentor during medical school. 7 MD
PhD students completed the survey and were removed from data analysis. Within the LIC cohort, 18 responded and 12 reported their mentor came from the clerkship. These 12 LIC surveys were compared to 49 TT
responses. Of the 12, 92% strongly agreed, compared to 49% of TT students, that their mentor motivated them to improve their work (p=0.009). LIC students were more likely to strongly agree that their mentors
stimulated them to think critically (p=0.02) and increased their self-confidence (p=.012). Additionally, 91% of LIC students strongly agreed that their mentors were important for their personal growth (p=0.02). There
was no significant difference between LIC and TT students in behaviors of mentors related to career development and professional growth.
CONCLUSIONS: In this pilot study, LIC students reported enhanced mentoring relationships as compared to their TT colleagues within certain mentoring domains. As LIC clerkships tend to involve a smaller number
of students, the sample size of this LIC is a potential limitation to the study. Qualitative studies and studies which include larger numbers of LIC students across multiple institutions would better elucidate mentorship
experiences in this unique type of clerkship.
Filename: 752555
Presenting Author: Scott Moerdler, MD
Department/Institution/Address: 255 west 94th st Apt 14R, New York, New York, 10025, United States
Phone: 9176203176
Fax:
Title: Preseason Pediatrics: A Preclinical Pediatric Exposure with Residents as Educator-Mentors
Scott Moerdler1, Suzanne Friedman1, Alefiyah Malbari1, Kathleen Gibbs1 and Blair Hammond1. 1Pediatrics, Mount Sinai, New York, NY.
BACKGROUND: Medical students have limited preclinical exposure to pediatrics. We performed a needs assessment of graduating medical students at our institution. They reported decreased knowledge, interest
and preparedness for the clerkship when starting their clinical years compared to other specialties.
OBJECTIVE: In order to increase preclinical opportunities, we created an optional experience, Preseason Pediatrics (PSP), focusing on pediatric-specific knowledge and clinical skills.
DESIGN/METHODS: Students were assigned resident mentors at the start of the program. The curriculum consisted of monthly didactic sessions developed and taught by residents. These were followed by resident
mentored hands on clinical experiences directly related to the topic of the month, where students applied knowledge and skills learned. Topics were designed to correspond with courses being taught in the medical
school at that time including: newborn physical exam, development, cardiac exam and common infectious diseases. The curriculum ended with a resident career panel. Participants completed a questionnaire to
assess clinical knowledge as well as perceptions of pediatrics before and after the program. At completion students also rated their residents as mentors and teachers.
RESULTS: 60 students (40% of the MS1 class) participated in the pilot program, 50 completed the pre and 43 completed the post assessments. Percent correct scores on a pediatric knowledge assessment increased
from 37% to 63% (p<0.05) and 83% reported feeling more prepared for their pediatric clerkship. 97% of the students rated their mentors as a good or above average educators and 90% reported that their learning
was comparable or better to faculty teachers. Overall, 95% of students would recommend PSP to other students.
CONCLUSIONS: PSP is a novel preclinical program introducing medical students to pediatrics. The combination of didactics and clinical experiences improved knowledge of pediatrics and perception of preparedness
for the clerkship. The role of residents as educators and mentors expands the available resources for students to identify mentors and develop their pediatric skills. Based on feedback we restructured the sessions for
the upcoming year to incorporate additional topics including pediatric rashes and nutrition. We are also expanding the curriculum to include a subsequent year, focused on skills utilized in the pediatric clerkship and
beyond.
Filename: 754298
Presenting Author: Megan M. Gray, MD
Department/Institution/Address: Neonatology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Main hospital 2nd Floor, Philadelphia, PA, 19104, United States
Phone: 2069195476
Fax:
Title: Visual Assessment of the Infant Larynx by Neonatology Fellows and Attendings
Megan M. Gray1 and Anne Ades1. 1Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Airway abnormalities are often encountered in infants admitted to the NICU and confer a high risk for morbidity. Neonatologists have frequent opportunities to visualize infant airways but have little
training in recognizing and documenting airway assessments, which can lead to missed opportunities for diagnosis.
OBJECTIVE: The many discrepancies between Neonatology and Otolaryngology airway evaluations at our institution prompted this study in order to quantify and describe this problem.
DESIGN/METHODS: Neonatology fellows (n=16) and attendings (n=24) were shown 10 images of infant airways obtained during bronchoscopy and asked to classify each airway as normal or abnormal and provide a
description of any abnormality as they would in the medical record. Each image was either of a normal infant airway or of an airway with a single abnormality. Errors were classified as one of five types: false positive
for pathology, false negative for pathology, errors in localizing the abnormality, errors in describing the abnormality and false secondary pathology. Descriptive answers were also evaluated using quantitative text
analysis
RESULTS: Fellows and attendings were able to correctly identify airways as normal or abnormal 85% and 75% of the time, respectively, with the majority of their misidentifications being of false positives for pathology.
There were an average of 1.3 errors per case for the fellows and 1.6 errors per case for the attendings, though fellows and attendings had different distributions of error types
Fellow Errors
Attending Errors
Error Type
total n=211 (%) total n=385 (%)
False Positive
20 (9%)
50 (13%)
False Negative
4 (2%)
12 (3%)
Incorrect Location
89 (42%)
137 (36%)
Incorrect Description
84 (40%)
123 (32%)
False Secondary Pathology 14 (7%)
63 (16%)
. Error rates for fellows did not correlate with training year (R2=0.06, p=0.4) or career number of infant intubations (R2=0.003, p=0.8). Error rates for attendings did not correlate with years as an attending Neonatologist
(R2=0.13, p=0.2). Quantitative text analysis demonstrated 104 uses of edema despite no image containing true edema, making this the most common misdiagnosis.
CONCLUSIONS: Fellow and attending Neonatologists commonly misidentify airway abnormalities when looking at images of infant airways. Inaccurate recognition and communication of airway pathology can lead to
delays in diagnosis and or incorrect management. More training is needed to teach airway assessment and accurate documentation to neonatal providers.
Filename: 755134
Presenting Author: Smitha R. Mathew, MD
Department/Institution/Address: 286 1st street Apt 2S, Mineola, NY, 11501, United States
Phone: 7187023156
Fax:
Title: Effectiveness of Using a Multimodal Educational Approach As a Resident Initiated Global Health Project
Smitha R. Mathew1, Alexandra Vinci1, Paul Lee1 and Arsenia Asuncion1. 1Pediatrics, Winthrop University Hospital, Mineola, NY.
BACKGROUND: A resident driven global health initiative was created at Winthrop-University Hospital in response to a growing interest among pediatric residents to better serve our growing El Salvadorian population.
The curriculum at our Academic Affiliated Hospital was based on an established curriculum with modifications to meld the needs and vision of the global health team. An initial trip was conducted as a needs
assessment to determine the mission of our global health team and it was decided that our primary focus would be education of both local medical and non-medical professionals.
OBJECTIVE: Create a resident driven curriculum based in their native language to train local physicians in the recognition and management of pediatric medical emergencies in El Salvador.
DESIGN/METHODS: Two day workshop composed of didactic, case based and simulation exercises tailored for local physicians was designed by our global health team in response to the needs of the local
community. The two day course was attended by 30 local physicians at various levels of training and specialties where all courses were conducted in Spanish. A pretest and post test was administered in order to
qualitatively measure the baseline knowledge of the trainees. A post course evaluation was also completed to determine effectiveness of the course along with feedback to modify current local practices. Resident pre
and post reflection was also administered to ascertain resident goals, expectations and level of satisfaction.
RESULTS:
CONCLUSIONS: Pre and post test analysis shows that physicians' knowledge of pediatric emergency management improved following the 2 day workshop. There was a noticeable improvement in the knowledge and
skills of the attendees. Post course evaluation suggests that most physicians would change their current emergency management based on this course. Resident post reflection also determined that they were
effective instructors and more culturally sensitive to the needs of the community
Filename: 751193
Presenting Author: Kim Derespina
Department/Institution/Address: Pediatrics, Stony Brook Children's Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, United States
Phone: 6314447711
Fax:
Is Presenting Author a Trainee? Yes, Other - Chief Resident
Title: Evaluation of Simulated Hand-Offs from Pediatric Residents To Faculty Using SBAR
Kim Derespina1, K. Fenton1, R. Blair1, D. Grossman1, C. Messina1 and R. Panesar1. 1Stony Brook Children's Hospital, Stony Brook, NY.
BACKGROUND: Physician hand-offs have significant variability and accuracy. Restrictions in resident duty hours increase physician hand-offs. The Joint Commission's National Patient Safety Goals support a
"standardized approach to hand-off communication." Though effective tools have been developed for routine hand-offs, we propose that hand-offs in the acutely critical setting require additional training and use of a
different tool. The Situation Background Assessment Recommendation (SBAR) hand-off tool provides a succinct, structured format for communicating critical information in an acute setting. Residents commonly
undergo educational hand-off training during orientation. Additionally, high-fidelity simulation provides opportunities to study trainees' knowledge acquisition, retention and performance. Limited data exist on the
efficacy of pediatric residency training of the SBAR hand-off from trainees to attending physicians in high-fidelity simulations.
OBJECTIVE: To determine if pediatric resident education of the SBAR hand-off tool during orientation is sufficient to teach adequate hand-off technique in high-fidelity simulations of acutely ill pediatric patients.
DESIGN/METHODS: Pediatric residents consented to participate in a high-fidelity simulation involving two critically ill patients in a simulated Pediatric Intensive Care setting. Conversations were recorded between the
resident and a pediatric intensivist while the resident provided hand-offs via phone of the patients. The resident and the intensivist then scored how well they gave and received the hand-off, respectively, using a
validated scoring tool. A study investigator scored the sign out using objective SBAR criteria.
RESULTS: Twenty-five pediatric residents have participated in the study. Preliminary data shows that 60% of residents identify the patient by name; only 24% prioritize patient acuity and 22% provide assessments.
Though 92% report any vital signs, only 68% provide physical exam findings, and 0% report allergy information.
CONCLUSIONS: Routine pediatric resident education of SBAR techniques during orientation is insufficient for adequate hand-offs in the simulated acute care setting. Resident hand-offs lacked structure, prioritization
of patient acuity, as well as communication and synthesis of an assessment. More intensive training in SBAR technique is warranted. High fidelity simulation-based education may provide a valuable training method
for this technique.
Filename: 752365
Presenting Author: Evan S. Fieldston, MD, MBA, MSHP
Department/Institution/Address: Department of Pediatrics, Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd, Philadelphia, PA, 19104, United States
Phone: 267-426-2903
Fax:
Title: Effects of an Educational Intervention on Pediatricians' Knowledge and Perceptions of Healthcare Costs and Value
Jennifer A. Jonas1, Jeanine C. Ronan1,2 and Evan S. Fieldston1,2. 1Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA and 2Pediatrics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA.
BACKGROUND: Since 2011, the American College of Physicians has emphasized a need for physicians to receive training in providing high-value, cost-conscious care. As part of this effort, in FY14, The Children's
Hospital of Philadelphia (CHOP) piloted a curriculum on healthcare costs and value for faculty in the Division of General Pediatrics.
OBJECTIVE: This study uses baseline and post-intervention surveys to gauge knowledge, perceptions and views on these issues, and to assess the efficacy of the pilot curriculum.
DESIGN/METHODS: Faculty in the Division of General Pediatrics at CHOP were asked to complete online surveys about their knowledge and perceptions about healthcare costs and value, and their views on the role
physicians should play in containing costs and promoting value. Baseline and post-intervention responses were compared. Responses were also analyzed based on how many sessions of the nine-part curriculum
respondents attended.
RESULTS: 62 faculty members completed the baseline survey for a response rate of 71%. 45 faculty members completed the post-intervention survey for a response rate of 63%. Reported knowledge of healthcare
costs and value increased significantly in the post-intervention survey (p=0.043, and p=0.000 respectively). Reported knowledge of healthcare costs, charges, and value also increased in association with number of
sessions attended (p=0.014, p=0.017, and p=0.000 respectively).
CONCLUSIONS: The pilot curriculum appeared to successfully introduce general pediatricians to concepts around healthcare costs and value, and initiated discussions about the role physicians can play in containing
costs and promoting value. Further educational initiatives, and increased cost transparency, are needed to help physicians translate knowledge into practice.
Filename: 752815
Presenting Author: Katherine Hodock, MD
Department/Institution/Address: Department of Pediatrics, Rutgers - New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, United States
Phone: 9084519530
Fax:
Title: Oral Presentations: Do One, See Yourself Do One, Do One Better
Katherine Hodock1 and Steven Eagle2,3. 1Rutgers - New Jersey Medical School, Newark, NJ; 2Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, NY and 3Hackensack University Medical Center,
Hackensack, NJ.
BACKGROUND: Oral presentations (OP) are the backbone upon which transitions of care are built, yet little evidence exists to define the most appropriate method of teaching students these skills. The current
teaching ranges from dedicated instructional sessions to direct attending feedback on rounds. While there is good evidence on methods for teaching history taking and physical exam (H&P) skills, almost no research
exists on best practices for OP skills. It has been demonstrated that a student watching a video of their own H&P skills allows for self-reflection and subsequently improves their skills.
OBJECTIVE: To assess whether video self-observation enhances oral presentations skills.
DESIGN/METHODS: All 3rd year students at one institution received a curriculum on oral presentation skills. The students then viewed a videotaped standardized interview (SI) and were required to present to an
attending. All students received immediate feedback after the session. The attendings evaluated the students using a standardized clinical observation form. After the initial session, the forty students were randomly
assigned into either the experimental (EX) or control (CN) group. The EX had an additional session of self-critique while watching their video among colleagues. The sessions were repeated after a three month
interval. An independent review of the video was done by outside attendings who also completed the evaluation.
RESULTS: Inter-rater reliability using the Wilcox-signed rank test demonstrated no statistical significant difference between the attendings (p=0.25). Mann-Whitney-U test demonstrated overall improvement in both
groups. Summary statement demonstrated the most significant difference (p=0.00148). Wilcox signed rank test demonstrated no statistical difference between the CN and EX groups. Using a difference-of-differences
analysis, there was a 0.3825 point difference in favor of the EX in the summary statement category between the groups.
CONCLUSIONS: Having participated in a new curriculum for oral presentations, the scores of both the CN and EX groups improved significantly. While there was a greater change noted in the EX group, due to the
small sample size it lacked the power to be a statistically significant change. The improvement in both groups suggests that the curriculum alone improves student oral presentation skills. Future research will focus on
an assessment prior to the implementation of the curriculum, and will include qualitative data as well.
Filename: 751487
Presenting Author: Mary Curtin, D.O.
Department/Institution/Address: Neonatal-Perinatal Medicine, Cohen Children's Medical Center, North Shore-LIJ Health System, 269-01 76th Avenue, New Hyde Park, NY, 11040, United States
Phone: 7184703440
Fax:
Title: Development of a Resident Education Program To Improve Pediatric Skin and Wound Care
Mary Curtin1 and Vita Boyar1. 1Neonatal-Perinatal Medicine, Cohen Children's Medical Center, North Shore- LIJ Health System, New Hyde Park, NY.
BACKGROUND: Recognition that the pediatric population especially ICU, neonatal and oncologic patients are at very high risk for skin injuries is on the rise. We observed gaps in our pediatric residents' ability to
recognize, prevent and treat common wounds and skin injuries.
OBJECTIVE: Improve resident knowledge of pediatric skin injuries and preventative care.
DESIGN/METHODS: We developed a didactic and small-group hands-on “Pediatric Skin and Wounds” curriculum. Pre-curriculum evaluation of resident knowledge was performed by a competency test and
assessment of orders accuracy in the EMR. The test was developed by a wound board–certified neonatologist. The hospital's wound team conducted audits of the EMR for accuracy/appropriateness of interventions.
The project was spearheaded by one of our residents. The seminar series consisted of four seminars intermixed with bedside case evaluations and multidisciplinary “de-briefing” meetings after reports of injuries such
as pressure ulcers, IV extravasations and skin tears. After one year a post-implementation competency test was administered. Audits of the hospital's EMR were done continuously and subjective evaluations of
residents' knowledge were ongoing by the wound physician and wound team members.
RESULTS: Our program demonstrated improved knowledge in a cohort of 64 residents as measured by the post-implementation competency test and audits of EMR orders accuracy. The competency test focused on
three major areas: 1. Skin physiology/pediatric wounds (20%increase in correct answers) 2. Wound healing physiology/therapeutic principles (8% increase) 3. Therapeutic products/prevention (10% increase). This
translates into increased knowledge as evident by a 40% increase in accuracy of EMR orders/appropriate preventative and therapeutic interventions. Residents reported satisfaction with the didactic curriculum and
improved understanding of the recognition, prevention and treatment of pediatric wounds.
CONCLUSIONS: Our curriculum incorporated pediatric skin and wound education through didactic and experiential learning. Important factors included small group bedside experience, protected time for residents to
attend seminars and discussion during “de-briefing” sessions with wound-team faculty. Residents' competence improved both quantitatively and subjectively. Recognition that pediatric patients are at high risk for
hospital-acquired wounds is growing; residents should be adequately educated and prepared for prevention and treatment of skin injuries.
Filename: 755244
Presenting Author: Noeet Elitsur, MD
Department/Institution/Address: Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, 800 Washington St, Box 44, Boston, Massachusetts, 02111, United States
Phone: 617-636-5322
Fax: 617-636 1456
Title: Lactation Education in MSIII- A Pilot Study of a Novel Education Tool
Noeet Elitsur1, Roger Edwards2, Rohith Vallu2, Krissy Mainello2, Jessica Davidson1, Maria Blanco3 and MaryAnn Volpe1,3. 1Division of Newborn Medicine, Floating Hospital for Children at Tufts Medical Center, Boston,
MA; 2Bouve College of Health Sciences, Northeastern University, Boston, MA and 3Tufts University School of Medicine, Boston, MA.
BACKGROUND: US health care providers' knowledge of breastfeeding (BF) practices are lacking, inhibiting optimal healthcare delivery to BF mothers and achievement of Healthy People 2020 BF goals.
OBJECTIVE: Develop and pilot test a novel educational intervention for 3rd year medical students aimed at improving knowledge and counseling skills in lactation and support of BF mothers.
DESIGN/METHODS: Students were divided into control (CG) and interventional (IG) groups. The CG received the current standard lactation education whereas the IG completed a one-hour online tutorial and
interacted with a novel computer animated patient, developed by our research team, to help with interaction and counseling skills. All groups received pre- and posttests covering the following content domains (CD):
BF basic knowledge, techniques, pharmacology, lactogenesis, breast milk storage/handling (BMSH) Demographic and personal experience data were also collected. CGs and IGs were further stratified into late 3rd
year students (Epoch 1) or early 3rd year students (Epoch 2) in order to pilot test the educational intervention.
RESULTS: Demographics, including male-female distribution, were similar in Epoch 1 and 2, but % females were greater in CG (61%) than IG (45%). Epoch 1 had greater previous BF education than Epoch 2 (24%
vs 6%). Mean IG pretest scores were similar between Epochs (62% Epoch 1; 61% Epoch 2), but were slightly different in CG (Epoch 1 CG 64%; Epoch 2 CG 56%). Mean IG posttest scores were higher in both
Epochs (68% Epoch 1; 66% Epoch 2) when compared to CG (65% Epoch 1; 61% Epoch 2). When evaluating individual subject data, while both IG and CG gained knowledge, the mean % knowledge gain was greater
in IG for each Epoch. Evaluating specific CDs, IG in each Epoch compared to the CG showed more profound % knowledge gain in all CDs except BF basic knowledge and BMSH.
CONCLUSIONS: While all students gained knowledge in BF and lactation, subjects exposed to our newly-developed novel educational tool gained further knowledge regardless of Epochs. This additional knowledge
gain with use of our novel educational tool occurred independent of level of training within the 3rd year medical curriculum. Educating medical students early in their careers may improve overall BF knowledge and
ultimately improve BF rates. Survey results to evaluate use of this knowledge and counselling skills in other rotations are in progress.
Filename: 750943
Presenting Author: Rasheda Z. Amin, MD
Department/Institution/Address: Pediatric Nephrology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, United States
Phone: 202-476-4625
Fax:
Title: Glomerular Hyperfiltration in Autosomal Dominant Polycystic Kidney Disease: A Retrospective Cohort Study
Rasheda Z. Amin1, Monica T. Cramer2, Robert J. McCarter3 and Lisa M. Guay-Woodford3. 1Pediatric Nephrology, Children's National Health System, Washington, DC; 2Pediatric Nephrology, University of Alabama,
Birmingham Children's Hospital, Birmingham, AL and 3Center for Clinical and Translational Research, Children's National Health System, Washington, DC.
BACKGROUND: In ADPKD children and young adults, GH is an early marker of renal disease progression, often precedes nephromegaly, and is associated with more rapid decline in renal function (Helal, CJASN
2011). These data suggest that in the standard clinical setting, accurate assessment of glomerular filtration (GFR) in ADPKD children is important. Evidence for GH may provide a rationale to initiate ACE inhibitor
(ACEI) therapy. Standard creatinine-based formulae, validated in primarily chronic kidney disease cohorts (Schwartz, JASN 2009), may not be appropriate for assessing GH. In contrast, GFR estimated using a
cystatin-C based formula strongly correlates (r=0.8) with GFR measured using technetium 99m DTPA in ADPKD children with GH (Filler, Ped Nephrol 2003).
OBJECTIVE: Conduct a retrospective analysis of ADPKD children with GH determined by the Filler formula and assess the effect of low dose ACEI therapy on GH.
DESIGN/METHODS: Chart review of 128 ADPKD patients followed in the Inherited Renal Disease Program at UAB and CNHS identified 37 patients (mean age 11.3 ± 4.7 years) with GH, defined as GFR > 2
standard deviations above mean for age. Eighteen (48%) were treated with low dose ACEI (+ACE) (lisinopril; mean dose 0.1 ± 0.08 mg/kg). On average, the (+ACEI) group was evaluated in 3 visits over a 1-3 years
vs. 1.5 visits over 2 years in the untreated group (-ACEI). Renal length, measured by ultrasound, was assessed using the MrNomogram (www.prevmed.sunysb.edu/jjc/MrNomogram).
RESULTS: Using a mixed effects multiple regression model controlling for age, blood pressure, and proteinuria, we determined that GH was higher over the observational period in the (+ACEI) group (171±21
ml/min/1.73m2) than in the (–ACEI) group (157±12 ml/min/1.73m2)(p=0.07). In addition, there was a suggestive correlation between GH and renal length in both groups (r=0.24; p=0.09).
CONCLUSIONS: Our data suggest that low dose ACEI does not mitigate GH in ADPKD children. However, the retrospective design precluded an independent assessment of underlying disease severity in both
groups. A prospective, longitudinal study is required to rigorously evaluate the potential role of ACEI on GH progression in ADPKD children. The study design should be informed by our data, and include a
randomized, placebo-controlled trial of alternative doses of ACEI, as well as serial assessment of renal volume.
Abstract Number: 11
Filename: 750152
Presenting Author: Lena E. Gottesman
Department/Institution/Address: 377 West 11th Street Apt 3D, New York, NY, United States
Phone: +1 (646) 5266822
Fax:
Is Presenting Author a Trainee? Yes, Medical Student
Title: Using Social and Economic Barriers To Predict Pediatric Renal Transplant Access and Success
Lena E. Gottesman1, Hanan Tawandrous2 and Chris Feudtner3. 1Temple Univ Sch of Med, Philadelphia, PA; 2SUNY Downstate, Brooklyn, NY and 3Children's Hosp of Philadelphia, Philadelphia, PA.
BACKGROUND: When deciding to transplant a child, socioeconomic factors are typically considered.
OBJECTIVE: Our goal was to determine whether specific social and economic situations predict access to and success of renal transplants in children. Median household income (MHI), history of patient non-adherent
behavior (NAB), and parental/guardian issues (PI) were analyzed as parameters to determine transplant access and graft success.
DESIGN/METHODS: A retrospective longitudinal cohort study of pediatric patients (<21 yo) followed at Downstate Medical Center or Parkside Dialysis Center divided into 3 groups. T: transplanted; NT: never
transplanted, on dialysis; FT: history of ≥ 1 failed transplant, back on dialysis. MHI was determined through US Census by zip code. NAB was defined as chart-notated missed medication or appointments or diet
non-compliance. PI was any home situation that was poorly conducive to transplant responsibilities, e.g. lack of parental presence and parental mental illness.
RESULTS: 24 patients ages 12 to 18 were included. For MHI, T and FT were compared and revealed no significant association with transplant access (p = 0.55). NAB was analyzed pre and post-transplant to
determine effect on both receipt and survival. T vs. NT revealed a small statistical difference between NAB in the pre-transplant period in those who kept their transplants vs those who had not yet received one (p =
0.03). T vs. FT revealed no significant difference in history of NAB after transplant in patients with graft success vs. loss (p = 0.82). A significant relationship was revealed when T and FT combined were compared to
NT to determine whether PI affect graft receipt (p = 0.001). A significant relationship was also found when T was compared to FT, demonstrating an association between PI and graft failure (p = 0.04). T was compared
to NT and FT combined and showed a significant association between PI and dialysis: there was an absence of PI in patients with functioning grafts and a high prevalence in those on dialysis (p = 0.002).
CONCLUSIONS: In contrast to MHI and NAB, involvement and capability of parents was found to be most critical to transplant access and success. Thus, there is more value in using PI to predict medical outcome
than other social and financial barriers. This data should help guide resource allocation to prioritize adequate home nursing and parental mental healthcare in order to benefit the health of the child.
Filename: 750065
Presenting Author: Donna J. Brezinski, MD
Department/Institution/Address: Little Sparrows Technologies, 176 Mystic Valley Parkway, Winchester, MA, 01890, United States
Phone: +1 (617) 752-2470
Fax:
Title: Artificial Skin Assay Predicts Phototherapy May Be Enhanced Through Optimization of the Angle of Incident Light
Donna J. Brezinski1, Shreyas Renganathan2, Chi N. Ta2 and Gary E. Gilbert2. 1Little Sparrows Technologies, LLC, Winchester, MA and 2VA Boston Healthcare System, Boston, MA.
BACKGROUND: Severe neonatal jaundice is a common condition treated with phototherapy. Blue light causes photoisomerization of bilirubin to forms more easily excreted. Efficacy of overhead phototherapy devices
is measured by mapping irradiance perpendicular to a 2-dimensional area within an infant outline. Bili-Hut is a novel phototherapy device with an arcuate LED array and reflective interior. Current efficacy metrics do
not consider the infant contour to optimize device development or predict efficacy.
OBJECTIVE: To develop a metric for evaluating effect of incident light angle on phototherapy efficacy .
DESIGN/METHODS: Artificial (phantom) skin was used to simulate optical properties of jaundiced neonatal skin. Skin phantom discs, 25mm x 1.5 mm, were adhered to an infant manikin at locations of clinically
relevant incident light angles. The manikin was exposed to light from a 23 x 28 cm flexible LED array (λmax = 463 nm) in either a planar or arcuate configuration (Bili-Hut) at a height delivering 36 µW/cm2/nm.
Bilirubin photoisomerization was measured with a novel optical assay, A463/A500, and an established assay.
RESULTS: Skin phantoms transmitted ~1% of perpendicular incident light; 0.5% when bilirubin (26 mg/dL) was added. Transmission decreased as incident angle increased, with 50% reduction at 45°. Isomerization
on the chest was 50% at 80 min, and equivalent with both configurations.
Rates at non-perpendicular incident locations were slower. Those with an angle > 60° from perpendicular had no measurable isomerization. Global efficacy of phototherapy was predicted by the sum of isomerization
rates. The sum was 20% higher for the Bili-Hutvs. planar.
CONCLUSIONS: Limited light transmission through skin phantoms suggests an increase in planar light intensity is unlikely to significantly boost efficacy. Our contour assay predicts that increasing the fraction of skin
exposed to perpendicular light will increase therapeutic efficacy and provides a metric for evaluating light delivery.
Filename: 752820
Presenting Author: Jessica Dodge, MS
Department/Institution/Address: Pathology, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030, United States
Phone: 12039849847
Fax: 18606791403
Title: Risk of Transfusion-Associated Necrotizing Enterocolitis (TA-NEC) per pRBC Transfusion in ELBW Infants
Jessica Dodge2 and Naveed Hussain1. 1Pediatrics, Connecticut Children's Medical Center, Hartford, CT and 2Pathology, University of Connecticut School of Medicine, Farmington, CT.
BACKGROUND: The diagnosis of NEC within 48 hr of pRBC transfusion in premature infants has been termed TA-NEC but the entity is still not well characterized.
OBJECTIVE: To determine the risk of NEC per pRBC transfusion based on (1) corrected gestational age (CGA=GA birth+completed wk of life) at time of transfusion and (2) the sequence number of transfusion.
DESIGN/METHODS: A retrospective study was done with all ELBW (<1000 gm BW) infants admitted to a single tertiary care NICU between July 1994 and June 2009. NEC was diagnosed based on Bell's criteria ≥
Stage 2. TA-NEC was defined as NEC within 48 hr of a pRBC transfusion. Each transfusion received by the infant over the NICU stay was noted and the risk of TA-NEC per 1000 transfusion was calculated.
RESULTS: Of the 6881 infants admitted, 818 were ELBW. NEC was diagnosed in 53 infants, 17 of which were classified as TA-NEC. There were no significant variations in transfusion or TA-NEC rates over the 15
years of the study. The total number of pRBC transfusions given were 3630 from CGA 22- 49 wks. The median number of transfusions per infant was 4 (range 0-27, IQR 5). The overall incidence of TA-NEC was
4.7/1000 transfusions. TA-NEC risk varied with CGA at time of transfusionand the sequence number of transfusion.
CONCLUSIONS: The overall incidence of TA-NEC is low and the practice in some NICUs of stopping feeds before, during or after a transfusion needs to be re-evaluated. Based on the risk profiles presented,
transfusions between 30-33 wks CGA and the 3rd-5th transfusion in a particular infant carry the highest risk. These findings need further validation.
Filename: 753408
Presenting Author: Deidre M. St. Peter, B.S.
Department/Institution/Address: Pediatrics, University of Maryland Baltimore School of Medicine, 110 S. Paca St, 8th Floor 8-S-163, Baltimore, MD, 21201, United States
Phone: 4103286003
Fax:
Title: Examining Vasopressor Use in the Hypotensive Premature Neonate
Deidre M. St. Peter1, Christiana L. Gandy1 and Suma B. Hoffman1. 1Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD.
BACKGROUND: 50% of preterm infants are defined as hypotensive. Use of vasopressors is an independent predictor of severe IVH and death.
OBJECTIVE: This study compares characteristics and outcomes of hypotensive patients treated with vasopressors to those not treated with these medications.
DESIGN/METHODS: A single center 3 year retrospective review was conducted on inborn infants 24-32 wks gestation. Demographic and clinical data including blood pressure(BP) parameters and therapy were
collected. Patients were determined to be hypotensive if they maintained a mean arterial blood pressure(MAP) < 30 for over 1 consecutive hour. Hypotensive patients were considered treated if they received
vasopressor medications. Differences in treated and non-treated infants were evaluated using T-test and Chi-square analysis for continuous and categorical data respectively. Mean BP parameters(mean arterial
pressure(MAP), systolic(SBP), diastolic(DBP)), and differences between minimum and maximum values in each group were collected in 12 hr intervals for the first 96hrs of life. Further, patients in the treated group
were further divided by number of medications received.
RESULTS: 111 patients in the cohort were defined as hypotensive. Treated patients (n=54) had significantly lower GA, BW, 5 min Apgar, and antenatal steroid use(p<.04). Treated patients were also significantly more
likely to have CLD, severe IVH, and Death(p<.004). Treated patients had significantly lower BP parameters over the first 96hrs
, but significantly higher fluctuations in MAP and SBP
. Patients treated with multidrug therapy were similar to patients treated with single therapy in their BW, GA, 5 min Apgar score, but were less likely to receive antenatal steroids(p .004), and more likely to have severe
intraventricular hemorrhage(p .007) and death(p .007).
CONCLUSIONS: Those treated with vasoactive medications tend to be more premature and have lower BP with higher fluctuations. In this group, especially those treated with multi-drug therapy, we see an increase
in adverse outcomes.
Filename: 754733
Presenting Author: Samuel Ajayi, MD
Department/Institution/Address: Neonatology, Saint Christopher's Hospital for Children, 3601 A Street, Philadelphia, PA, 19134, United States
Phone: 215-427-5202
Fax:
Title: Ultrasound for Central Vascular Catheter and Endotracheal Tube Position in the NICU- A Pilot Study
Samuel Ajayi1, David Saul2, Mindy Horrow3 and David L. Schutzman4. 1Neonatology, Saint Christopher's Hospital for Children, Philadelphia, PA; 2Radiology, Children's Hospital of Philadelphia, Philadelphia, PA;
3
Radiology, Einstein Medical Center Philadelphia, Philadelphia, PA and 4Pediatrics, Einstein Medical Center Philadelphia, Philadelphia, PA.
BACKGROUND: Infants in the neonatal intensive care unit (NICU) often require support with endotracheal tubes (ETTs), umbilical arterial/venous catheters (UACs/UVCs), and peripherally inserted central venous
catheters (PICCs). Evaluation of these support devices with radiographs exposes these infants to ionizing radiation.
OBJECTIVE: Evaluate the reliability of ultrasound (US) localizationof ETTs, UACs, UVs and PICCs as compared to the current gold standard of radiographic localization.
DESIGN/METHODS: This prospective, IRB-approved pilot study was performed in a level IIIB NICU serving an inner city population. Consecutive babies of any birth weight and gestational age who required
placement or adjustment of an ETT, UAC, UVC or PICC were recruited. Standard x-ray confirmation of these support devices was obtained. US evaluation of the devices was obtained by members of the Department
of Radiology as soon as possible, and within 24 hours in any case, without prior review of the radiographs. Results obtained by US were compared to the gold standard radiographic interpretation.
RESULTS: Twenty six patients (19 male, 7 female) were imaged for a total of 43 lines and tubes: 16 UVCs, 11 UACs, 9 PICCs, and 7 ETTs. 40 support devices (93%) were visualized with US. All were concordant
with x-ray. 33 were correctly positioned and 7 were malpositioned. US identified the location of UVCs in all 16 cases (100%), UACs in all 11 (100%), PICC in 7 (78%), and ETT in 6 (86%). Portal vein thrombosis was
identified in all 3 malpositioned UVCs. Catheter tip thrombus was present in 1 well positioned UAC.
CONCLUSIONS: US reliability was excellent for evaluation of UACs/UVCs and good for PICCs and ETTs. These results support the use of US as a primary modality for umbilical catheter and possibly PICC and ETT
assessment. US can also provide more information regarding line complications than X-ray. Future directions include training NICU caregivers for point of care US, and larger studies for PICCs and ETTs.
Filename: 754683
Presenting Author: Suma Hoffman, M.D.
Department/Institution/Address: Pediatrics, University of Maryland Baltimore School of Medicine, 110 S. Paca St, 8th Floor 8-S-163, Baltimore, MD, 21201, United States
Phone: 4103286003
Fax:
Title: Cerebral and Renal Perfusion Trends Over Time in Premature Neonates
Suma Hoffman1, Larry S. Magder2 and Rose M. Viscardi1. 1Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD and 2Epidemiology and Preventive Medicine, University of Maryland
Baltimore School of Medicine, Baltimore, MD.
BACKGROUND: Regional perfusion may be a more useful indicator of hemodynamic status than blood pressure (BP) alone, but there is limited data examining perfusion over time in the extremely premature.
OBJECTIVE: To examine the relationship of cerebral and renal perfusion over time in infants 24-29 weeks GA. We hypothesize that renal perfusion will fluctuate with BP changes, but with intact autoregulation,
cerebral perfusion will be unaffected.
DESIGN/METHODS: Inborn neonates 24 - 29 wk GA who had continuous intra-arterial monitoring by 12h of life were enrolled in a prospective observational cohort study. Demographic and clinical data was recorded.
Regional saturations (cerebral, rSO2-C and renal, rSO2-R) and intra-arterial BP were continuously recorded for the first 96h of life or until the A-line was removed. Patients were categorized by GA and whether they
received hypotension treatment. For each group, the mean±SD for rSO2-C and rSO2-R were calculated in 6h increments. Non-parametric estimates of the mean rSO2-C and rSO2-R over mean arterial pressure
(MAP) was plotted per child.
RESULTS: Nineteen subjects were enrolled (24-26 wk GA, N=13; 27-29 wk GA, N=6) and 11 were treated for hypotension. In the first 24h of life, measures of rSO2-C and rSO2-R tended to be higher in the more
mature GA group (80% rSO2-C and 83% rSO2-R vs 72% rSO2-C and 75% rSO2-R respectively), but this difference did not reach significance. In both GA strata, there was high cerebral-renal(C-R) perfusion
correlation. Generally, cerebral perfusion was higher than renal perfusion. Both rSO2-C and rSO2-R decreased for the first 48h then reached a plateau. In patients who received hypotension therapy, C-R perfusion
was more strongly correlated as was C-R-MAP correlation
.
CONCLUSIONS: Cerebral and renal perfusion decrease over time demonstrating increased oxygen utilization during postnatal transition. However, premature infants have higher rSO2-C, suggesting lower cerebral
oxygen extraction. High C-R-MAP correlation indicates loss of autoregulation that is exaggerated by hypotension therapy.
Filename: 754492
Presenting Author: Judith S. Mercer, PhD
Department/Institution/Address: Pediatric Research, Women & Infants Hospital, 90 Plain Street, Providence, RI, 02903, United States
Phone: 01-401-480-1542
Fax:
Title: Impact of Maternal Factors on Circulating Cord/Peripheral Blood Cytokines and Stem Cells (SC) in Preterm Infants (PT)
Judith S. Mercer1,2,3, Vineet Bhandari4, Debra A. Erickson-Owens1,2,3, Betty R. Vohr2,3, Richard Tucker2, William Oh2,3 and James F. Padbury2,3. 1College of Nursing, University of Rhode Island, Kingston, RI; 2Pediatrics,
Women & Infants Hospital, Providence, RI; 3Alpert School of Medicine, Brown University, Providence, RI and 4School of Medicine, Yale University, New Haven, CT.
BACKGROUND: The effect of delayed cord clamping (DCC) on circulating cytokines/SChas not been evaluated.
OBJECTIVE: We hypothesized DCC would result in lower interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) levels and higher numbers of SC than immediate clamping (ICC) in PT infants.
DESIGN/METHODS: We randomly assigned 208 enrolled women with singletons (< 32w gestational age or GA) to either ICC (<10s) or DCC (30-45s). Cord blood (CB) was collected for IL-6/VEGF/SC at birth,
peripheral blood for IL-6 at 6h and VEGF/SC levels at 20h. Log transformation was used for the regression models.
RESULTS: PT in the ICC and DCC groups weighed 1136+350 and 1203+352g and the GA was 28.4+2 and 28.3+2w respectively. Cord clamping time was 7+6 (ICC) vs. 33+16s (DCC). More women with
preeclampsia (PEC) were in the IC group (37vs 22%, p=0.02) and more women with premature rupture of membranes/preterm labor (PROM) were in the DC group (54 vs 75%, p=0.002).There were no differences
between the infants with DCC or ICC on any of the cytokines or SC at birth. There were no differences at 6 or 20h except for a trend for 20h SC levels to be higher in the DCC group (median 30 vs 22cells/ml, p=0.07).
In mothers with PEC the infant had significantly lower values (IL-6 at birth: 7.4 vs 25pg/ml; VEGF at 20h: 58 vs 365pg/ml; SC at birth: 14 vs 30cells/ml, at 20h: 7.2 vs 49cells/ml at 20h; all p<0.001). Presence of PROM
led to significantly higher values (IL-6 at birth: 50 vs 8pg/ml; VEGF at 20h: 376 vs 58pg/ml; p<0.001). SC were significantly higher in the infants exposed to PROM at birth/20h (32 vs 15 and 54.5 vs 7cells/ml, p
<0.0001). Linear regression controlling for GA, gender, and DCC showed that PEC lowered, while PROM raised IL-6 at birth by 91% and 840%, respectively (p<0.0001). PEC resulted in lower, while PROM raised
VEGF at 20h by 88% and 596%, respectively (p<0.0001). SC in CB and 20h were reduced 60 and 84% in PEC and PROM increased it by 164% and 610%, respectively (p<0.0001). When controlling for PEC and
PROM in one model, exposure to PROM raised SC at birth and at 20h by 107% and 395%, respectively (p<0.0001).
CONCLUSIONS: DCC did not influence cytokine or SC levels. After controlling for confounders, PEC reduced, while PROM increased IL-6/VEGF/SC values. We conclude that maternal factors can significantly impact
on circulating cytokines and SC in PT infants.
Filename: 756364
Presenting Author: Sanjeet K. Panda, MD
Department/Institution/Address: 100 woods road, PMB - 481, Valhalla, NEW YORK, 10595, United States
Phone: 3618766940
Fax:
Title: Short-Course, Low- Dose Postnatal Betamethasone in ELBW babies: A Pilot Study Power Analysis
Sanjeet K. Panda1, Yuanyi Li1, Vanessa V. Mercado1 and Edmund F. La Gamma1. 1Regional NICU, Maria Fareri Children's Hospital, Valhalla, NY.
BACKGROUND: BPD is a major neonatal complication affecting around 50% of ELBW neonates. 2010 AAP Policy statement on postnatal glucocorticoids, suggests that it may be considered for ELBWs on
mechanical ventilation after 1-2 weeks of age to abate progression of BPD. Our center previously showed promising benefits with postnatal BETA that mimics the antenatal treatment regimen on limiting the
progression of lung disease with few side-effects (DeCastro, et al J Perinatol 29:297, 2009).
OBJECTIVE: Low dose (0.125mg/kg im), short course (q24h x 3d) postnatal BETA would reduce the need for ventilatory support.
DESIGN/METHODS: In this prospective pilot study, the primary endpoints were reduction in peak inspiratory pressure (PIP) and oxygen (FiO2) within 7d after initiation of treatment plus changes in weight gain,
glucose intolerance and uremia. PIP,MAP and FiO2 collected 7d pre and post-BETA dosing. We included ELBWs who were intubated & ventilated > 10d postnatal age plus worsening respiratory status (increasing or
unchanged support x 72h defined as FiO2 > 0.4 or MAP > 10). Statistical analysis was done using SAS version 9.4.
RESULTS: BETA was given between postnatal 15-47d. PIP and FiO2 requirements were significantly lower at 7 days compared to day of administration (p=0.008 for PIP; p=0.03 for FiO2). Significant reductions were
also seen when compared with 7d prior to administration (p=0.02 for PIP; p=0.009 for FiO2). No significant difference in rate of weight gain, hyperglycemia or uremia were noted.
CONCLUSIONS: Our Pilot study proves that there is a significant effect of BETA in decreasing the PIP and FiO2. We plan a randomized control trial comparing all respiratory and clinical outcomes between BETA and
control groups from birth through discharge. Based on this pilot, for a continuous outcome superiority trial, in order to detect clinically significant differences in FiO2, MAP and PIP before & after BETA, at a p<0.05,
anticipating 10% crossover, we would enroll 70 participants to power study at 0.8.
Filename: 753550
Presenting Author: Sean M. Bailey, MD
Department/Institution/Address: 25 Cedar Dr., Roslyn, NY, 11576, United States
Phone: 212-263-0201
Fax:
Title: Impact of Indomethacin Prophylaxis on Clinical NICU Outcomes in ELBW Preterm Infants
Sean M. Bailey1, Elaine Carelus2, Rebecca Zarchin1 and Pradeep V. Mally1. 1Pediatrics, New York University School of Medicine, New York and 2Stony Brook School of Medicine, Stony Brook.
BACKGROUND: Prophlyactic indomethacin usage in extremely low birth weight (ELBW) preterm infants is administered with the intention of preventing severe neurologic injury. Research examining indomethacin
prophylaxis is limited and best practice remains unclear. Once thought standard care, most recent research has demonstrated no reduction in death or poor neurodevelopmental outcomes. We therefore have stopped
this practice in our NICUs in recent years.
OBJECTIVE: To determine any impact that stopping routine use of prophylactic indomethacin treatment has had on the clinical course of our ELBW infants.
DESIGN/METHODS: We conducted a retrospective, IRB exempt chart review on inborn infants <1000 grams and <29 wks born between January 2010 and June 2014. Two subject cohorts: those who received
indomethacin prophylaxis and those who did not. Our primary aim was to determine for any difference in the prevalence of severe neurologic injury (Grade 3 IVH, Grade 4 IVH, or PVL) and mortality during the NICU
course.
RESULTS: 51 subjects included, 30 had received indomethacin prophylaxis and 21 had not. There was no difference between groups in terms of gestational age (26.9±1.3 v. 26.6±1.7 wks), birth weight (802±151 v.
726±169 g), proportion male; proportion singleton. There was also no difference in their early NICU course including Apgar scores, intubation, surfactant administration, and initial hematocrit and platelet levels. Eighty
percent of the infants in the prophylaxis group at discharge had survival free of severe neurologic injury v. 76% in the non-prophylaxis group, which was not significantly different. In addition, there was no significant
difference between the prophylaxis and non-prophylaxis groups in individual diagnosis of grade 1 IVH (27% v. 10%), Grade 2 IVH (3% v. 10%), Grade 3 or 4 IVH (10% v. 5%), PVL (7% v. 5%), or death (7% v. 14%),
respectively. There was also no difference in non-neurological clinical outcomes that can be potentially impacted by indomethacin, including prevalence of chronic lung disease, prevalence of intestinal perforation and
necrotizing enterocolitis, number of days requiring TPN; peak BUN and creatinine levels.
CONCLUSIONS: Prophylactic indomethacin use to prevent severe neurologic injury, in our population, is likely not effective. This research supports our current practice and the information gathered can add to the
literature to help further clarify this aspect of neonatal critical care.
Filename: 752223
Presenting Author: Jherna Balany
Department/Institution/Address: Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, 245 N. 15th Street, New College Building, MS 1029, Philadelphia, PA,
19102, United States
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Effect of Hypothermia on Na+, K+ ATPase Enzyme Activity in Newborn Piglet Brain Following Hypoxia
Jherna Balany1, Shadi Malaeb1, Panagiotis Kratimenos1 and Maria Delivoria-Papadopoulos1. 1Dept. of Pediatrics, Drexel University College and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Hypothermia (HT) is used to treat infants with hypoxic ischemic encephalopathy (HIE) but neurologic outcome of these infants remains guarded. Understanding the mechanisms of hypothermic
neuroprotection will help develop strategies to augment neuroprotection by HT. We have previously shown that acute hypoxia (Hx) results in free radical damage to the lipid membranes in the cerebral cortex with a
concurrent decrease in Na+, K+ ATPase enzyme activity, an index of neuronal cell membrane integrity. Na+, K+ ATPase enzyme is located in the plasma membranes of all animal cells and actively pumps sodium out
of cells while pumping potassium into cells.
OBJECTIVE: The present study tests the hypothesis that hypothermia preserves Na+, K+ ATPase activity in the newborn piglet brain following hypoxia.
DESIGN/METHODS: Ventilated newborn piglets were exposed to hypoxic FiO2 0.07 for 1 hr and then returned to FiO2 0.21 to restore O2 and blood pressure. Piglets were studied acutely following hypoxia, or were
either cooled to 33°C or remained at normal body temperatures for 4 hrs following hypoxia. Na+, K+ ATPase activity in the membrane fraction of the cerebral cortex was measured spectrophotometrically as the
ouabain-sensitive rate of liberation of inorganic phosphate expressed as µmole/mg protein/hr; Mean ± SEM.
RESULTS: Na+, K+ ATPase enzyme activity (µmole/mg protein/hr; M±SEM) was 22.5 ± 1.7 in Normoxic normothermic piglets (Nx-NT; N=3), and 19.6±1.1 in Nx- hypothermic piglets (Nx-HT; N=4, p=NS vs Nx-NT).
The enzyme activity decreased to 16.0 ± 0.15 acutely following hypoxia (N=2; p<0.05 vs Nx). Four hours after HI, Na+, K+ ATPase activity increased to 23.9 ± 2.2 in normothermic piglets (Hx-NT4Hr; N=3; p<0.05 vs
acute Hx; p=NS vs Nx-NT) and to 19.4 ± 0.7 in hypothermic piglets (Hx-HT; N=5; p=NS vs Nx-HT).
CONCLUSIONS: We conclude that Na+, K+ ATPase activity is decreased acutely following hypoxia, and returns to levels comparable to those seen in normoxia in both hypothermic and normothermic piglets during
recovery. We propose that hypoxic cerebral injury can persist despite restoration of Na+, K+ ATPase activity. We suggest that hypothermia could maintain long-term cerebral Na+, K+ ATPase activity after HI.
Mechanisms by which HT offers neuroprtotection may be multifactorial and related to inflammation, oxidative stress and other factors.
Filename: 752662
Presenting Author: Swati Murthy, MD
Department/Institution/Address: 848 S Swanson Street, Philadelphia, NY, 19147, United States
Phone: 3154270499
Fax:
Title: Does Post-Pyloric Feeding Improve Respiratory Outcomes in Preterm Infants with Respiratory Failure?
Swati Murthy1 and Zubair Aghai1. 1Neonatology, Nemours at Thomas Jefferson, Philadelphia, PA.
BACKGROUND: Gastroesophageal reflux (GER) is common in preterm infants. Micro-aspiration (MA) from GER may contribute to respiratory failure in preterm infants. Preterm infants are at increased risk for MA due
to supine positioning and feeding tubes that hold the gastroesophageal sphincter open. Furthermore, intubated preterm infants typically have uncuffed endotracheal tubes. Currently, there is no effective therapy for
preventing MA in preterm infants. Anti-reflux surgery is associated with short-term benefits in some with severe BPD but requires an invasive procedure. Some clinicians use post-pyloric (PP) feeds to prevent MA,
though there is no data supporting this.
OBJECTIVE: To see if changing from gastric to PP feeds affects the respiratory status of very low birthweight (VLBW) infants.
DESIGN/METHODS: This is a retrospective analysis of VLBW infants (birthweight <1500g) who received PP feeds for ≥5 days in our NICU, January 2009 to August 2014. We looked at respiratory parameters [type of
support, fractionated oxygen (FiO2), mean airway pressure (MAP)] prior to starting PP feeds, 7 days after and 14 days after starting PP feeds.
RESULTS: Forty-seven infants [birthweight 758±261g, gestational age 25.7±.3 weeks (mean±SD)] met inclusion criteria. The median age of starting PP feeds was 73 days (range 10-128). The median duration of PP
feeding was 17 days (range 5-64). There was no significant difference in the FiO2 (p=0.09, p=0.9) and MAP (p=0.6, p=0.9) 7 and 14 days after starting PP feeds. There was also no significant difference in the number
of infants on mechanical ventilation (p=0.8, p=0.3) and CPAP/HFNC (p=0.8, p=0.8) 7 and 14 days after starting PP feeds. More infants were on NC/RA 14 days after starting PP feeds than there were prior (p=0.02).
1 day prior to PP feeds
7 days PP feeds
FiO2(mean±SD)
58±21.4
51±19.8
57±25.7
Mean Airway Pressure
14.8±5.1
13.8±4.5
15.0±4.2
Mechanical Ventilation (%)
25 (53)
23 (49)
19 (40)
CPAP or HFNC
20 (43)
18 (38)
18 (38)
2 (4)
6 (13)
10 (21)
NC or RA
14 days PP feeds
Key
SD: Standard deviation
CPAP: Continuous positive airway pressure (includes noninvasive positive pressure ventilation)
HFNC: High flow nasal cannula
NC: Nasal cannula
RA: Room air
CONCLUSIONS: PP feeds may marginally improve respiratory status in VLBW infants with respiratory failure. The improvement seen in this study may be related to lung disease that improved with time and nutrition.
More studies are needed to evaluate the safety and efficacy of PP feeds.
Filename: 751800
Presenting Author: Vikramaditya Dumpa, MD
Department/Institution/Address: Pediatrics, State University of New York at Buffalo, 219 Bryant St, Buffalo, NY, 14222, United States
Phone: +17168787673
Fax:
Title: Efficacy of Surfactant in Hypoxemic Respiratory Failure in Late Preterm and Term Neonates
Vikramaditya Dumpa1, Indirapriyadarshini Avulakunta1 and Satyan Lakshminrusimha1. 1Division of Neonatology, Department of Pediatrics, State University of New York at Buffalo, Buffalo, NY.
BACKGROUND: Surfactant is currently approved for prevention and treatment of respiratory distress syndrome (RDS) in preterm infants. Surfactant deficiency can be primary as in RDS or secondary to inactivation in
meconium aspiration syndrome or pneumonia leading to hypoxemic respiratory failure (HRF). Inhaled nitric oxide (iNO) is the only approved medication for HRF in late preterm and term infants and improves
oxygenation in about two-third of these infants. We evaluated the efficacy of surfactant in HRF at this gestational age (GA).
OBJECTIVE: To assess the oxygenation response and frequency of surfactant use in late preterm and term infants with HRF.
DESIGN/METHODS: Retrospective data were obtained (10/11 to 10/13) from infants who received Infasurf® (calfactant) treatment. The decision to administer surfactant was based on clinical status, degree of
respiratory support and radiological features. Oxygenation response to surfactant was assessed by Oxygenation Index (OI) or by change in PaO2/FiO2 (P/F) ratio (≥20 mmHg considered as responders). Oxygen
saturation index(OSI=MAPX100XFiO2/SaO2) was also compared as some infants did not have arterial access.
RESULTS: 389 infants of all GA received surfactant of which 139 infants were ≥ 34 w GA [36%: 85 late preterm (22%) and 54 term (14% of all infants receiving surfactant)]. 53 out of these 139 infants required more
than one dose of surfactant. There was a significant improvement in P/F ratio, OI and OSI with surfactant.
Parameter,unit Before Surfactant After Surfactant P value
FiO2,%
0.46±0.23
0.34±0.18
<0.0001
MAP,cm H20
11.3±3.1
11±3.07
0.1
SaO2, %
94.1±7.8
96.8±3.3
<0.0001
PaO2,mmHg
58.5±21.8
66±29.8
0.04
PCO2,mmHg
51±14
49±14.2
0.1
OI
12.5±16
9.9±12.6
0.03
OSI
5.7±4.8
4.3±3.9
<0.0001
215±120
<0.0001
P/F ratio,mmHg 165±87.5
The response to surfactant was not different in late preterm vs. term infants. Infants with RDS had a significantly greater decrease in FiO2 compared to non-RDS conditions. Two-thirds of late preterm and term infants
had an increase in P/F ratio ≥20 mmHg after surfactant. Outborn infants (77% vs 59%;p<0.05) and male infants (77% vs 55%;p<0.02) were more likely to receive multiple doses of surfactant.
CONCLUSIONS: Surfactant use is common among late preterm and term neonates and it improves oxygenation with a response rate similar to iNO. Surfactant therapy must be considered in HRF of any severity in
newborns of all GA groups.
Filename: 754891
Presenting Author: Zoe O. VanOrden
Department/Institution/Address: Pediatrics, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, United States
Phone: 315-383-1720
Fax: 518-262-5881
Title: Delivery Room Prophylactic Surfactant (PS) at 27-28 Weeks: Is It Necessary?
Zoe O. VanOrden1 and Meredith L. Monaco-Brown1. 1Pediatrics, Division of Neonatology, Albany Medical College, Albany, NY.
BACKGROUND: Despite meta-analyses touting significant improvements in mortality and prevalence of chronic lung disease (CLD) as a result of PS usage, others question its use in older preterm infants for whom
the benefit of PS may not outweigh the risks of intubation without analgesia. Guidelines from international associations vary significantly in their PS recommendations for preterm neonates 26-30 weeks' gestation.
OBJECTIVE: To evaluate outcomes that occurred in 27-28 week infants before and after an institutional change in usage of PS.
DESIGN/METHODS: Retrospective chart review following a change in NICU guidelines (January 2013) in which recommendations for PS target population was changed from all infants under 29 weeks' to those under
27 weeks'. Subjects were collected by database search of all 27-28 week infants born 18 months before (PRE) and 18 months after (POST) the guideline change. Demographic data and outcomes were evaluated
using non-parametric ANOVA and Dunn's multiple comparisons test to determine significant differences between the two groups.
RESULTS: There were no significant differences between groups in all the variables reviewed.
PRE (mean+SD) POST (mean+SD) P-value
(n=39)
(n=42)
GA (weeks)
27.88 (±0.59)
28.00 (±0.46)
>0.05
Male (=1)
0.58 (±0.49)
0.54 (±0.50)
>0.05
Multiple (=1)
0.12 (±0.33)
0.30 (±0.46)
>0.05
Maternal tobacco/drugs (=1)
0.23 (±0.42)
0.30 (±0.46)
>0.05
Prenatal steroids complete (=1)
0.56 (±0.50)
0.61 (±0.49)
>0.05
Prenatal steroids incomplete (=1) 0.35 (±0.48)
0.30 (±0.46)
>0.05
No prenatal steroids (=1)
0.07 (±0.27)
0.09 (±0.33)
>0.05
# Surfactant doses
1.41 (±0.96)
0.50 (±0.70)
>0.05
# Intubation attempts
2.02 (±1.30)
1.19 (±1.46)
>0.05
Ventilator days
7.10 (±10.10)
2.02 (±3.10)
>0.05
Hospital days
68.07 (±20.66)
61.9 (±22.89)
>0.05
Pneumothorax (=1)
0.02 (±0.16)
0.07 (±0.26)
>0.05
Pulmonary hemorrhage (=1)
0.07 (±0.27)
0.00 (±0.00)
>0.05
Death (=1)
0.02 (±0.16)
0.14 (±0.35)
>0.05
CLD (=1)
0.69 (±0.46)
0.52 (±0.50)
>0.05
CONCLUSIONS: In a NICU where 92% of its 27-28 week neonates receive at least one dose of prenatal steroids, we found no difference in outcomes (CLD, ventilator days, or death) after discontinuing PS in these
infants. Although the n is limited, there is a possibility that current international guidelines are based on evidence that may not apply to today's premature infant. More studies may be useful to redefine criteria (or need)
for PS.
Filename: 754289
Presenting Author: Sara Berkelhamer, MD
Department/Institution/Address: Neonatology, Women and Children's Hospital of Buffalo, 219 Bryant, 3rd Floor, Buffalo, NY, 14222, United States
Phone: 3125439225
Fax:
Title: Essential Care for Small Babies (ECSB) Improves Knowledge, Performance, and Confidence in Caring for Small Babies
Sara Berkelhamer1, Carl Bose6, Sherri Bucher2, Marsha Campbell-Yeo3, Douglas McMillan3, Susan Niermeyer4 and Nalini Singhal5. 1University at Buffalo SUNY, Buffalo, NY; 2Indiana University, Indianapolis, IN;
3
Dalhousie University, Halifax, NS, Canada; 4University of Colorado, Aurora, CO; 5University of Calgary, Calgary, AB, Canada and 6University of North Carolina, Chapel Hill, NC.
BACKGROUND: Prematurity and low birth weight are leading causes of global neonatal mortality; most of these deaths occur in low-resource settings. A low-cost, skills-based educational program, Essential Care for
Small Babies (ECSB) was developed to teach basic care of small, well babies and complement training in basic neonatal resuscitation and essential newborn care. ECSB utilizes small group learning, simulation
based teaching and educational methodology similar to that used in the Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) programs.
OBJECTIVE: To evaluate the acceptability and educational quality of the ECSB program.
DESIGN/METHODS: Field trials were performed in Nepal (N) and Uganda (U). Participants included nurses and physicians, all of whom care for small babies, from 3 countries in Asia (Nepal, India and Bangladesh)
and Africa (Uganda, Ethiopia and Kenya). Experienced providers were trained as facilitators and subsequently led training of providers. Multiple choice questions (MCQ) and confidence assessments (CA) were
performed pre and post training. Objective structured clinical evaluations (OSCE) assessed skills and counseling related to skin-to-skin care, placement of nasogastric tube and feeding of breast milk. Average scores
and standard deviation (SD) for MCQs and CAs were determined and compared by T-test with significance defined as p<0.05. Focus Group Discussions (FGD) were used to assess program acceptability.
RESULTS: 23 facilitators (12N, 11U) and 42 providers (24N, 18U) participated after informed consent. Performance on MCQs improved significantly with average pre and post-training scores of 26.0 (± 3.0 SD) and
28.7 (± 0.9 SD) for facilitators and 23.9 (± 2.4 SD) and 27.3 (± 1.8 SD) for providers. Similarly, confidence pre and post training improved significantly with pre and post training scores of 4.13 (± 0.8 SD) and 4.9 (± 0.3
SD) for facilitators and 3.8 (± 0.5 SD) and 4.8 (± 0.3 SD) for providers. Provider scores on the 2 OSCEs averaged 11.0 (± 1.0 SD) and 18.2 (± 2.5 SD) out of a possible score of 12 and 22 respectively. FGD results
indicated that the program was well accepted by both Asian and African participants.
CONCLUSIONS: The ECSB program was well received, promoted acquisition of skills and increased learner's knowledge and confidence.
Filename: 754676
Presenting Author: Sara K. Berkelhamer, MD
Department/Institution/Address: Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant, 3rd Floor, Buffalo, NY, 14222, United States
Phone: 3125439225
Fax:
Title: Dysregulated Endothelin Signaling Persists After Neonatal Hyperoxia and Is ROS-Dependent
Sara K. Berkelhamer1, Kathryn N. Farrow2 and Paul T. Schumacker2. 1Pediatrics, University at Buffalo SUNY, Buffalo, NY and 2Pediatrics, Northwestern University, Chicago, IL.
BACKGROUND: About 1/3 of infants with moderate to severe bronchopulmonary dysplasia (BPD) also develop pulmonary hypertension (PH). Endothelin (ET1) is a potent vasoconstrictor and its dysregulated
signaling may contribute to severity of disease. The murine neonatal hyperoxia model induces a BPD phenotype with PH and can be used to study endothelin signaling in the developing lung.
OBJECTIVE: To determine if newborn mice with hyperoxia-induced BPD and PH demonstrate prolonged dysregulation of endothelin signaling.
To determine if antioxidant therapy after neonatal hyperoxia restores normal endothelin signaling.
To determine whether endothelin A receptor (ETAR) signaling contributes to persistent PH in the murine model.
DESIGN/METHODS: Newborn C57BL/6 mice were exposed to 14 days of 21%O2(control, C) or 75%O2(BPD) to induce PH and RVH. Mice were subsequently recovered in 21%O2and sacrificed at 56 days. Serum
ET1 levels were determined by ELISA. Lung tissue ETA and ETB receptor expression was measured by western blot. Additional mice were treated with N-acetylcysteine (NAC, 1 g/kg PO daily) from day 28-56 or an
ETA receptor antagonist (BQ123, 10 mg/g SQ daily) or vehicle (V) from day 14-21 with echocardiography prior to sacrifice to determine pulmonary acceleration/ejection time (PA/ET).
RESULTS: No differences in ET1 levels were detected at 56 days (C 1.81±0.14, BPD 1.67±0.12). However, BPD mice demonstrated increased ETAR and ETBR expression as compared to controls (ETAR: C
1.0±0.15, BPD 1.94±0.54; ETBR C 0.99±0.08, BPD 1.74±0.31). Treatment with NAC attenuated expression of both ETAR and ETBR (ETAR: C+NAC 1.0±0.11, BPD+NAC 1.32±0.18; ETBR C+NAC 0.98±0.04,
BPD+NAC 0.84±0.11). As 56 day-old BPD mice no longer exhibit PH, BQ123 was administered day 14-21. Treatment resulted in accelerated recovery of pulmonary hypertension by PA/ET (C+V 0.33±0.014, BPD+V
0.27±0.007, C+BQ123 0.32±0.008, BPD+BQ123 0.30±0.004).
CONCLUSIONS: Neonatal hyperoxia results in prolonged dysregulation of endothelin signaling with altered receptor expression in adult mice. Antioxidant therapy abrogates this response, suggesting that ongoing
oxidative stress may contribute to disease pathogenesis. Accelerated recovery with BQ123 treatment suggests that PH is reversible and ETAR-dependent.
Filename: 750386
Presenting Author: E. A. Jensen, MD
Department/Institution/Address: Division of Neonatology, The Children's Hospital of Philadelphia, 34th and Civic Center Blvd, 2 Main - Neonatology, Philadelphia, PA, 19107, United States
Phone: 267-648-2720
Fax:
Title: Delivery After Midnight Is Associated with Increased Risk-Adjusted Odds of Severe IVH in VLBWs
E. A. Jensen1 and S. A. Lorch1. 1Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Off-peak hour delivery may increase risk for adverse neonatal outcomes, however there is limited data on the association between time of delivery and outcomes predictive of neurodevelopment.
OBJECTIVE: To assess the association between time of delivery and BPD, ROP, and severe IVH in a large, population based cohort of VLBWs (BW: 500-1499g).
DESIGN/METHODS: A retrospective population based cohort was formed of all VLBWs without severe congenital anomalies born between '99-'09 in CA and PA using linked birth certificates and discharge ICD-9
records (n=64,060). Logistic regression assessed the association between off-peak delivery (12-6 am) and neonatal outcomes. Model 1 adjusted for year only. Model 2 included year and infant and maternal
demographic data. Model 3 included model 2 and pregnancy complications. Risk-adjusted probabilities were determined with model 3.
RESULTS: The 16,673 infants born at off-peak hours had lower GA (29 vs 28.6 wks, p<.001) and BW (1071 vs 1059g, p<.001). C-sections and maternal diabetes and hypertension were less common for off-peak
births but pregnancy complications were more common. The highest risk-adjusted probability for each outcome occurred between 3-6 am except for BPD at 12-1 am (Figure). In the initial model, off peak delivery
increased the odds of all study outcomes (Table). After adjustment for demographic factors, the risk of death and severe IVH remained increased. Once maternal illness and pregnancy complications were considered,
only severe IVH was associated with off-peak delivery.
Table. Odds ratios (95% CI) for each neonatal outcome
Outcome
Model 1
Death
1.24 (1.17-1.32) 1.15 (1.08-1.23) 1.04 (.97-1.11)
Severe IVH 1.3 (1.19-1.42)
Model 2
1.2 (1.09-1.31)
Model 3
1.18 (1.08-1.3)
BPD
1.08 (1.03-1.13) 1.0 (.94-1.05)
1.02 (.97-1.08)
ROP
1.06 (1.01-1.11) 1.02 (.97-1.07)
1.12 (1.04-1.20)
CONCLUSIONS: Among VLBWs, off-peak delivery is associated with increased risk of adverse outcomes. Except for severe IVH, this risk is accounted for by differences in demographic characteristics and pregnancy
complications.
Filename: 754183
Presenting Author: Kabir M. Abubakar, MD
Department/Institution/Address: Pediatrics/Neonatology, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC, 20007, United States
Phone: 202-444-8569
Fax: 202-444-4747
Title: Effect of Electronic Medical Record Implementation on Medication Errors in a Tertiary Care NICU
Kabir M. Abubakar1, Anthonia Umeh1 and Jeanne Rorke1. 1Neonatology/Pharmacy/Nursing, Georgetown University Hospital, Washington, DC.
BACKGROUND: Medication errors (MEs) are a significant cause of morbidity in hospitalized patients. Infants in the Neonatal Intensive Care Unit (NICU) are particularly at risk because their drug dose is dependent on
weight and age, which change over time. Most MEs in the NICU occur during drug dose calculation where a decimal point error can result in a 10-fold dose difference. Studies in adults and children have shown that
computerized physician order entry (CPOE) systems reduce medication errors and adverse drug events (ADEs). Our NICU has a rigorous medication error tracking program and implemented an electronic medical
record system (EMR). We evaluated the frequency and types of medication errors before and after the implementation of EMR.
OBJECTIVE: To evaluate the effect of CPOE on the frequency and types of MEs before and after the implementation of an EMR in the NICU.
DESIGN/METHODS: EMR was implemented in our tertiary care academic NICU in September 2013. All Residents, Fellows, Nurse Practitioners, Nurses and dispensing Pharmacists were trained on the use of the
EMR. The accuracy of all orders was checked by the pharmacist and bedside nurse. The frequency and types of all MEs were recorded over a 12-month period after EMR (period 2) and compared to the 12 months
before EMR (period 1). Data were analyzed using Chi-square.
RESULTS: Our overall ME rates were low but there was an increase in all errors especially prescription and 10-fold errors after EMR implementation. Though there were substantially more orders due to higher census
and acuity in period 2, there were no other changes in our patient population or staffing patterns during this time
Period 1 Period 2
Total # of Orders
31582
47, 177 *
Total # of Errors
35
92 *
Total # of Patient Days
6805
7404
Total Error Rate per 1000 patient days
5.14
12.4*
Total Error rate/100 orders
0.12
0.19
Total # of Prescription Errors
23
66*
Total # Ten Fold Errors
5
11 *
Prescription Error rate/100 orders
0.08
0.14
Dispensing Error rate /100 orders
0.02
0.03
Nursing Error rate /100 orders
0.01
0.02
*=P<0.05
CONCLUSIONS: Implementation of EMR based CPOE did not reduce medication errors in our NICU. This may be related to the initial learning curve involved with the implementation of a new system. A vigilant error
monitoring and tracking system is still needed to prevent/reduce medication errors in the NICU.
Filename: 753832
Presenting Author: Maheswari Arumugam, MD
Department/Institution/Address: Division of Neonatology, department of Pediatrics, Saint Peters University Hospital, 254 Easton avenue, New Brunswick, New Jersey, 08903, United States
Phone: 732 745 8523
Fax:
Title: Outcome of Room Air Resuscitation in Very Low Birthweight Infants
Maheswari Arumugam1, Mujahid Anwar1 and Shakuntala Chandra1. 1Division of Neonatology, Department of Pediatrics, Saint Peters University Hospital, New Brunswick, NJ.
BACKGROUND: Majority of the preterm infants need some kind of respiratory assistance. VLBW infants are susceptible to oxidant injury from the use of excess supplemental oxygen .Recent studies have shed light
on the appropriateness of room air for resuscitating preterm infants.We used the same preductal saturation monitoring parameters recommended by NRP since fetal partial pressure of oxygen in the blood is similar
across gestational ages and hence oxygenation of both term and preterm infants is the same at the moment of birth. we embarked a quality improvement project to improve the outcomes and reduce oxygen toxicity in
preterm infants
OBJECTIVE: To improve compliance to maintain oxygen saturations in the recommended range by beginning room air resuscitation in all preterm infants ≤ 1500gms and monitor the outcomes
DESIGN/METHODS: We began resuscitation with room air and increased in increments to achieve the desired saturation.Monitored compliance by reviewing documentation by physician and RT. Outcomes such as
days of respiratory support, ventilator needs and surfactant therapy, BPD, ROP and Mortality were measured.We were able to achieve our goal By implementing a respiratory therapy,nursing policyand By education
of nurses RT and physicians.We compared 2 groups:Gr A: Infants <1500gms who were begun resuscitation at 100 percent fio2 and was adjusted to maintain sats between 85 to 92. Gr B: were begun at Room air and
fio2 increased until preductal pulse oximeter showed saturations that matched the table as per NRP guidelines at min of age Ttest for continuous variables, chi-square was used for categorical variables
RESULTS: We achieved 100% compliance with the practice of beginning room air resuscitation in infants <1500gms.Percentage of infants who needed surfactant before and after intervention reduced from 66.6 to
52.7% (P=0.2). There was no statistical difference in mean ventilator days or CPAP days and resp support in NICU. But there was an improvement in BPD from 7.7-4.39% (p=0.7) ROP from 51.2 to 44% (p=0.5)
mortality from 10.2to 7.7% (P=0.8)
CONCLUSIONS: We successfully changed our practice of beginning room air resuscitation in preterm infants <1500gms in the delivery room and adjusting the oxygen delivery to maintain saturations as per NRP
recommendations and this intervention showed a trend in Reduced need for surfactant, Reduced BPD, Reduced ROP, Reduced mortality. There was no disadvantage withour intervention
Filename: 753759
Presenting Author: Heideh H. Matterson, MD
Department/Institution/Address: Pediatrics, New York University Langone Medical Center, 317 East 34th Street, 9th Floor, Room 902, New York, NY, 10016, United States
Phone: 5136736071
Fax:
Title: Frequent Training Is a Key Element To Maintaining Neonatal Resuscitation Skills
Heideh H. Matterson1, Demian Szyld2, Brad R. Green3, Heather Howell1, Martin V. Pusic2, Pradeep V. Mally1 and Sean M. Bailey1. 1Pediatrics, New York University Langone Medical Center, New York, NY;
2
Emergency Medicine, New York University Langone Medical Center, New York, NY and 3Emergency Medicine, New York University Langone Medical Center, New York, NY.
BACKGROUND: With an increase in duty hour restrictions and the role of mid-level providers, opportunities for residents to practice live-time neonatal resuscitation (NRP) skills are becoming less frequent. Following
NRP training, the point at which skills are unable to be maintained at acceptable levels remains unclear.
OBJECTIVE: To determine a temporal correlation between NRP skill decay and the time at which any training last occurred.
DESIGN/METHODS: Prospective observation study of pediatric residents at NYUSOM. Each subject was randomly assigned to either the role of an airway or cardiac NRP team member. The last date that subjects
had any formal neonatal resuscitaion training was noted. Subjects worked in pairs to perform a neonatal resuscitation sequence utilizing a high-fidelity model at our simulation center. Subjects were de-identified by
wearing caps/masks, while the video focused only on the infant model. Sessions were recorded and later scored by 2 blinded NRP instructors, each of whom assigned subjects a global proficiency rating (GPR) of
performance to determine a mean score. Values of 1 (frequent errors, needs redirection, improper technique), 2 (minimum required level of skill, need redirection/support), 3 (expected level of skill, adequate
proficiency, little redirection) and 4 (highly skilled, good technique, no redirection) were used. A value of ≥ 2 was considered the minimum level at which skills would lead to a favorable outcome. GPR and days since
last training were analyzed using a Pearson's correlation with two-tailed test.
RESULTS:
28 total subjects, all but 2 were evaluated twice within a 1 year period. A significant correlation was found between days since prior training and GPR (p< 0.01). No one with less than 130 days of training scored below
2.
CONCLUSIONS: NRP skills decrease with time, often below an acceptable level. With frequent teaching, it appears that all providers should be able to administer appropriate resuscitative skills to a neonate.
Filename: 751169
Presenting Author: Heideh H. Matterson, MD
Department/Institution/Address: Pediatrics, New York University Langone Medical Center, 317 East 34th Street, 9th Floor, Room 902, New York, NY, 10016, United States
Phone: 5136736071
Fax:
Title: Rate of Neonatal Resuscitation Skill Decay Using a Simulation-Based Deliberate Practice and Mastery Learning Booster Session Model
Heideh H. Matterson1, Demian Szyld1, Brad Green2, Heather Howell1, Pradeep V. Mally1 and Sean M. Bailey1. 1Pediatrics, New York University Langone Medical Center, New York, NY and 2Emergency Medicine, Ohio
State University, Columbus, OH.
BACKGROUND: Use of simulation debriefing, video, and classroom-based lectures have not demonstrated significant improvement in neonatal resuscitation program (NRP) skill decay. A newer method,
simulation-based deliberate practice (DP), has shown to prevent decay. DP includes focused/repetitive practice, performance measurements, and informative feedback. Studies have shown that DP helps retain NRP
skills. Utilizing DP in combination with mastery learning (ML), in which clinical skills are measured against an achievement standard, has not been examined for NRP.
OBJECTIVE: To determine a) if a combined simulation-based DP-ML session proves effective in preventing the decay of NRP skills and b) the frequency required of such training to maintain NRP proficiency.
DESIGN/METHODS: Prospective descriptive study. 32 residents (28 test & 4 control subjects) were randomly assigned to receive DP-ML intervention either 7 (Early Group) or 9 (Late Group) months after NRP
certification as either an airway or cardiac participant. A baseline video-taped NRP code was first held to determine decay. After faculty assessment/expert modeling, participants underwent individual DP-ML
intervention and a code session was repeated. After 4 and 2 months, respectively, members of both groups returned for a follow-up code session. Videos were scored by 2 blinded NRP instructors using a validated
criteria scoring tool. Performance scores of 10/12 (airway)& 7/9 (cardiac) were considered sufficient to provide proficient resuscitation.
RESULTS: There was significant increase in skills after the booster DP-ML session from baseline (p<0.01), which did not significantly decline at either 2 or 4 months. There was no difference in skill decay between the
early v. late groups.
Early Airway Group (n = 7)
Late Airway Group (n = 7)
p-value
Baseline Score
9.5
9.5
NS
Post Intervention Score
11.3
10.7
NS
Retention Score
10.8
11.1
NS
Early Cardiac Group (n = 7)
Late Cardiac Group (n = 7)
p-value
Baseline Score
6.8
6.3
NS
Post Intervention Score
8.6
8.6
NS
Retention Score
7.5
8.2
NS
CONCLUSIONS: Booster sessions of DP-ML can improve resuscitation skills, which do not decline significantly either at 2 or 4 months. Skills at both 7 and 9 months after NRP training may decline below an
acceptable level. We recommend that DP-ML sessions could be held at 4 month intervals in order to maintain proficient NRP skills.
Filename: 751174
Presenting Author: Alexandra Vinci, MD
Department/Institution/Address: Department of Pediatrics, Winthrop University Hospital, 259 First Street, Mineola, NY, United States
Phone: 516-641-5963
Fax:
Title: A Quality Improvement Initiative To Improve Rates of Normothermia in the Delivery Room Using a Checklist
Alexandra Vinci1, Shahidul Islam1, Nazeeh Hanna1 and Amrita Nayak1. 1Department of Pediatrics, Winthrop University Hospital, Mineola, NY.
BACKGROUND: Very low birth weight (VLBW) infants are at increased risk of hypothermia from deficiencies of brown fat and immature nervous systems. Delivery room environment plays an important role in the
development of hypothermia in VLBW babies. Hypothermia (temperature <36°C) can result in unwanted outcomes such as hypoglycemia and neurological impairment. Each 1°C decrease in body temperature is
associated with a 75% increase in mortality.
OBJECTIVE: Our aim was to reduce hypothermia in VLBW infants born at Winthrop University Hospital (Regional Perinatal Center) by 25% using a simplified checklist. We intended to further prove its utility by
temporarily discontinuing its use in 2014 and reanalyzing the data.
DESIGN/METHODS: A delivery room checklist was created to reduce the incidence of hypothermia among VLBW infants (<32 weeks gestation) admitted to the NICU. Retrospective chart reviews assessed the
project's effectiveness for two years (2012 and 2013) after its implementation. Use of the checklist was temporarily stopped for six months in 2014. The incidence of hypothermia was again measured retrospectively
and compared to previous years. Cochrane-Armitage test was used to evaluate trend over the years. Chi-Square test was used to compare proportion of hypothermia.
RESULTS: Among all VLBW infants <32 weeks, 53% had admission temperatures <36°C in 2011 before implementation of checklist as compared to 29% in 2012 after it was started. There was a plateau in the rate
of hypothermia at 31% in 2013. The decrease in hypothermia overall from 2011-2013 was significant (p=0.007). When the checklist was stopped in 2014, hypothermia increased to 39%, significantly higher than in
2012 and 2013. As expected, the incidence of hypothermia correlated with smaller birth weight and gestational age except for the year 2012 (the first year of intervention), where there was no correlation between
incidence of hypothermia and birth weight or gestational age.
CONCLUSIONS: Simple measures put in place to prevent hypothermia, such as a checklist, are effective if well executed and complied with. Non-compliance of the checklist resulted in a decrease of normothermia
for VLBW babies, further supporting its utility. Periodic re-education and enforcement of these measures should be done to maintain success.
Filename: 751071
Presenting Author: Christina Freibott
Department/Institution/Address: Neonatology, Christiana Neonatology, MAP-1, Suite 217, 4745 Ogletown-Stanton Roads, Newark, DE, 19713, United States
Phone: 3027332410
Fax: 3027332602
Title: Parental and Staff Perspectives of Minor Increase Over Minimal Risk Without Direct Patient Benefit Research in the NICU
Christina Freibott1, Ursula Guillen1,2, Amy Mackley1 and Robert Locke1,2. 1Neonatology, Christiana Care Health System, Newark, DE and 2Pediatrics, Jefferson Medical College, Philadelphia, PA.
BACKGROUND: Infants comprise a potentially vulnerable research population and receive special protections. Category 406 (45 CFR Section 46.406) provides guidance for research involving “more than minimal risk
without the prospect of direct benefit”. IRB approval is permitted in Category 406 when “likely to yield generalizable knowledge which is of vital importance for the understanding or amelioration of the subjects' disorder
or condition”. Parents are surrogate decision-makers for infants. Currently, there are no data on NICU parent or staff perceptions regarding Category 406 research.
OBJECTIVE: To assess NICU parental and staff perspectives of Category 406 research.
DESIGN/METHODS: Four research scenarios to 4 types of infants were presented to NICU parents and staff with an anonymous Likert response questionnaire for willingness to have their own child participate.
Altruism belief was also assessed. Parents were selected and stratified based on their infant: ≤31 wks; 34-36 wks; Term in NICU minimal illness; Term not in NICU.
RESULTS: 60 parents and 30 staff participated. There was no difference between the parent groups. Combined parent results Table 1. Staff were more likely to consent to extra blood draws. There was no difference
between parents and staff concerning altruism belief.
Would you give permission for the following research procedure on your child..
Research Procedure
Definitely Yes Probably Yes Probably No Definitely No
Drawing 1 extra vial of blood for research purposes when other blood is being obtained for clinical purposes. (Would not require an extra blood draw).
46%
37%
9%
8%
Drawing 1 extra vial of blood for research purposes only (Would require an extra blood draw)
23%
35%
30%
12%
2 echocardiograms (heart ultrasound).
24%
52%
23%
5%
MRI brain without sedation
15%
29%
33%
23%
MRI brain with sedation
9%
22%
31%
38%
CONCLUSIONS: This is the first study to assess parent and staff perspectives of minor increase over minimal risk without direct benefit research in the NICU setting. Overall there is general alignment between
parents and staff concerning 406 risk research. This should give parents, researchers, staff and oversight regulators confidence in the current process. Next steps include understanding how non-English speaking
parents, racial/ethnic/cultural differences, health literacy and previous interactions with the health care community affect beliefs and responses.
Filename: 751572
Presenting Author: Michael M. Henry, MD
Department/Institution/Address: 355 16th Street, Apt 3R, Brooklyn, NY, 11215, United States
Phone: 3019222992
Fax:
Title: Correlation of Birth Weight and Placental Weight Ratio To Postnatal Cardiac Function in Intrauterine Growth Restricted Infants
Michael M. Henry1, Clarissa Aldape1, Simrun Kaur1, Xaio Yang Zhang1, Nayaab Khawar1, Manoj Chhabra1, Carolyn Salafia1, Pramod Narula1 and Ashraf Gad1. 1Department of Pediatrics, New York Methodist Hospital,
Brooklyn, NY.
BACKGROUND: Intrauterine growth restriction (IUGR) is defined as birth weight (BW) less than the 10th percentile for gestational age (GA). This condition complicates as much as 5% of all deliveries. It is known that
vital organs, such as the heart, are affected by being IUGR. There is evidence of cardiac dysfunction in IUGR children, as well as being a risk factor in itself for cardiovascular disease into adulthood. However, little is
known about cardiac function in this group of infants in the period of life shortly after birth. Concurrently, it is known there are placental pathology differences between IUGR and appropriate for gestational age (AGA)
infants.
OBJECTIVE: Our study aims to find a correlation between placental pathology parameters and 2D-echocardiogram (Echo) measurements, as a predictive marker of cardiac dysfunction in IUGR infants.
DESIGN/METHODS: This is a retrospective study using data from IUGR and AGA infants born at New York Methodist Hospital during 2012 and 2013, who had placental pathology reports from birth and Echo reports
done in the first week of life. Significant differences between IUGR infants (n=37) and AGA infants (n=71) were BW, GA, height, head circumference, parity, preeclampsia, Apgar score at 1 and 5 minutes and maternal
admission mean arterial blood pressure, which were all accounted for using linear regression analysis. Placental pathology (PP) factors were placental weight (PW), placental thickness and BW to PW ratio (BW/PW
ratio). Echo parameters were interventricular septal thickness during systole and diastole (IVSs and IVSd), left ventricular internal dimension during systole and diastole (LVIDs and LVIDd), left ventricular posterior wall
thickness at end systole and diastole (LVPWs and LVPWd), IVS/LVPW ratio, shortening fraction (FS), left ventricular volumes (LV mass vol and LV mass "C" d).
RESULTS: Our data showed that there was a significant correlation between BW/PW ratio and LVPWd (p <0.03, r= −0.3) in the IUGR group of infants.
CONCLUSIONS: An abnormal BW/PW ratio is associated with significant cardiac changes in IUGR infants shortly after birth. These findings can help further elucidate the role of PP as a predictive marker for cardiac
dysfunction in IUGR infants, and the need for close follow up upon discharge.
Filename: 752300
Presenting Author: Natalia A. Isaza, MD
Department/Institution/Address: 3504 Dundee Driveway, Chevy Chase, MD, 20815, United States
Phone: 202-256-3462
Fax:
Title: Parental Stress Before and After Skin To Skin Contact in the NICU
Natalia A. Isaza1, Khodayar Rais-Bahrami1, Mariam Said1 and Mauricio Cabrera2. 1NICU, Children´s National Medical Center, Washington, DC and 2Industrial Engineering Department, University of Puerto Rico at
Mayagüez, Mayagüez, PR.
BACKGROUND: NICU parents can experience high levels of stress due to: infant's clinical status; NICU environment; separation/inability to protect baby from pain/procedures. Stress can alterate maternal-infant
bonding, emotional/physical health, decrease breastfeeding, increase divorce. There is limited data on the effects of skin to skin (S2S) on the stress level of NICU parents
OBJECTIVE: Assess if S2S correlates to reported maternal stress; determine which clinical variables, including S2S, correlate statistically with reported stress level.
DESIGN/METHODS: Pilot study. Explained S2S with pictures/videos to parents. Patients acutely ill excluded. The Modified Parental Stress Scale NICU was provided pre/post S2S. Parents rated sources of stress on
a Likert scale (1:not stressful, 5:extremely stressful), 3 domains: Unit environment, Infant Behavior & Appearance, parental role alterations.
Data from 26 mothers with BW 0.38-3.7 kg, age 3-109 days, and GA 23-41 weeks. 57% on room air, 39% nasal canal or high flow O2, 4% mechanical ventilation. 58% born by c-section, 77% male.
Statistical Procedure:
• Regression Analysis of Stress Score
• ANOVA to test each of the 21 regression coefficients measuring linear effect on Stress Score
• Significance value of alpha = 10%
Assumptions of the residuals looked satisfactory
• Normality verified by Kolmogorov Smirnov test (p-value>0.15)
• Independence verified by correlation with order of data (p-value>0.90)
• Equality of variance assessed using Levene's test on S2S (p-value>0.90)
RESULTS: All mothers reported stress level decrease after S2S. Almost all items had a statistical reduction in maternal stress level, major decrease on: Separated from infants, Unable to hold, Feeling helpless,
General NICU experience.C-section was associated with increase stress
CONCLUSIONS: Difference between Pre/Post S2S measurements was significant at an alpha value of 5%. S2S can be used as a technique to decrease the stress level of NICU mothers.
Future directives include identify change in mothers' visits and breastfeeding rates
Filename: 750885
Presenting Author: Sarah A. Nitka, DO
Department/Institution/Address: Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1508, New York, NY, 10029, United States
Phone: 2012405952
Fax:
Title: Impact of Pasteurization on the Oligosaccharide Concentration of Human Breast Milk
Sarah A. Nitka1, Aimee R. Herdt2, Javier Pacheco-Quinto4, Caryn Peters2, Nancy Mejias-Cepeda2, Annemarie Stroustrup1, Robert D. Voyksner3 and Denise C. Hassinger2. 1Pediatrics, Icahn School of Medicine at
Mount Sinai, New York, NY; 2Pediatrics, Morristown Medical Center, Morristown, NJ; 3LCMS Limited, Durham, NC and 4Biomedical Research Institute of New Jersey, Cedar Knolls, NJ.
BACKGROUND: Despite decades of improvements to preterm formulas, human milk remains the best and safest enteral nutrition for preterm infants. Human milk feeding is associated with a decreased incidence of
sepsis and necrotizing enterocolitis (NEC) among very and extremely preterm infants. Specific human milk oligosaccharides are thought to play a preventative role against NEC. If a mother's breast milk is inadequate
or unavailable, administration of pasteurized donor breast milk to very low birth weight infants is recommended. Holder pasteurization is a widely used method of processing breast milk by donor banks in the United
States and the impact of pasteurization on the concentration of oligosaccharides in human milk is unclear.
OBJECTIVE: To evaluate the impact of two different methods of human breast milk pasteurization on the concentration of a specific oligosaccharide, diasialyllacto-N-tetraose (DSLNT), which has been shown to
improve survival and reduce NEC in neonatal rats.
DESIGN/METHODS: Pasteurized and unpasteurized breast milk from six donors was evaluated in two batches. Frozen milk was thawed, pooled (n=3), treated, and analyzed by LC/MS (ESI-Q-TOF). Treated milk was
heated to 62.5 ᴼC for 30 minutes (Holder pasteurization) or heated to 72 ᴼC for 15 seconds (flash pasteurization). Samples were filtered, purified and concentrated prior to MS analysis.
RESULTS: Holder pasteurization decreased the concentration of DSLNT in breast milk (68.1% ±5%), while flash pasteurization had no effect on the concentration of DSLNT in identical breast milk aliquots.
Table 1. ESI-Q-TOF Analysis of DSLNT
Results*
Peak Area DSLNT Conc (µM)
% Loss of DSLNT w/pasteurization
Unpasteurized
4.09 x 106 177.5 ± 24
---------------
Holder Pasteurized
1.63 x 106 57.0 ± 10**
68.1 ±5
Flash Pasteurized
4.52 x 106 201.5 ± 43
No Loss
Breast Milk Treatment
*Data are presented as the mean of two sample batches ± SE
**p<0.05, Unpaired students t-test
CONCLUSIONS: In this small pilot study, flash pasteurization was superior to Holder pasteurization in preserving the DSLNT oligosaccharide concentration in donor breast milk. Confirmation of this result in a larger
number of samples and evaluation of the impact of pasteurization methods on other breast milk components is ongoing.
Filename: 750554
Presenting Author: Keri N. Fugarolas, MD, FAAP
Department/Institution/Address: Neonatology, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, United States
Phone: 215-290-5090
Fax: 215-427-8192
Title: Combined Effect of Hypoxic Ischemic Encephalopathy and Controlled Hypothermia on Ampicillin Pharmacokinetics in Neonates
Keri N. Fugarolas1,2, Ogechukwu R. Menkiti1,2, Wayne II S. Moore3, Robert W. Mason3 and Jeffrey J. Cies1,2. 1St. Christopher's Hospital for Children, Philadelphia, PA; 2Drexel University College of Medicine,
Philadelphia, PA and 3Alfred I. duPont Hospital for Children, Wilmington, DE.
BACKGROUND: Perinatal asphyxia may cause derangements in multiple organ systems, including altered renal function and hypoxic ischemic encephalopathy (HIE). Controlled hypothermia (CH) independently has
been shown to alter normal physiologic functioning, including decreasing the glomerular filtration rate and the effective volume of distribution. The pharmacokinetics (PK) of ampicillin (AMP), a commonly used
medication for the treatment of presumed sepsis in neonates, are unknown in the setting of HIE and CH.
OBJECTIVE: We aimed to evaluate the combined effect of moderate to severe HIE and CH on AMP PK.
DESIGN/METHODS: Hospitalized neonates with moderate to severe HIE undergoing CH received high dose IV AMP 100 mg/kg/dose q8h for suspected meningitis between May-December 2013. Each patient
contributed 3 blood samples over the dosing interval for AMP concentration determination by liquid chromatography/tandem mass spectroscopy. A non-compartmental PK analysis was conducted to determine the
half-life (t1/2) and volume of distribution (Vd). The percentage of the dosing interval with free drug concentrations above the MIC (fT>MIC) was calculated using an MIC of 8 and 16 mcg/mL. Bactericidal exposure was
defined as ≥ 50% fT>MIC. The probability of target attainment (PTA) > 90% for each MIC was defined as optimal.
RESULTS: Seven neonates contributed 21 AMP concentrations. The median gestational age was 40 weeks (range 37-41 weeks). The mean ± SD birth weight was 3.36 ± 0.78 kg. The mean ± SD t1/2 was 5.32 ± 1.87
hours, as compared to a reported t1/2 of 3.2 hours in term and late preterm newborns (p > 0.05). The mean ± SD Vd was 0.42 ± 0.11 L/kg, as compared to a reported Vd of 0.4 L/kg in term and late preterm newborns
(p > 0.05). The mean ± SD trough value was 90 ± 17.4 mcg/mL. At the MICs of 8 and 16 mcg/mL, the PTA for the high dose AMP regimen was 100%.
CONCLUSIONS: This is the first study to describe AMP PK in neonates with HIE undergoing CH. These data suggest that the combined effect of HIE and CH does not have an impact on the PK of AMP in term
newborns. Further, the high dose AMP regimen used for suspected meningitis provided appropriate pharmacodynamic exposures for the entire dosing interval.
Filename: 755317
Presenting Author: Maheswari Ekambaram, MD
Department/Institution/Address: Pediatrics, Einstein Medical Center, 5501 Old York Road, Pediatric Administration, Paley 1321, Philadelphia, PA, 19141, United States
Phone: 2023204252
Fax:
Title: Predictors of Term Infants' Birth Weight in Pregnant Teenagers
Maheswari Ekambaram1, Johelin De Freitas1, Sharina Rajbhandari1, Jessica Geaney1 and Matilde Irigoyen1. 1Pediatrics, Einstein Medical Center, Philadelphia, PA.
BACKGROUND: Prepregnancy obesity and excessive pregnancy weight gain have been associated with greater birth weight in term infants. However, preeclampsia, smoking and teenage pregnancy appear to
increase the risk of low birth weight. Few studies have looked at the impact of independent predictors on birth weight in teenage pregnancy.
OBJECTIVE: To examine the independent predictors of birth weight in term newborns born to teen mothers.
DESIGN/METHODS: We conducted a retrospective cohort study of all singleton live term (≥ 37 weeks) infants born between January 2012 and October 2013 to mothers ≤18 years of age, at an academic medical
center in Philadelphia, PA. Maternal variables included demographics, parity, pre-pregnancy BMI, weight gain, number of prenatal visits, smoking, alcohol and drug use, preeclampsia, diabetes, infant gestational age.
We performed multivariable linear regression on birth weight.
RESULTS: During the study period 523 live singleton newborns were born to mothers ≤18 years; 71 were excluded due to lack of data on prepregnancy BMI and 42 due to prematurity, leaving a final sample of 410.
Mean maternal age was 17±1.2 years (range 13-18); 65% were African American, 25% Hispanic, 7% Caucasian; 85% primiparous; 99% had 1+ prenatal visit; 6% smoked tobacco; 6% smoked marijuana. Mean
prepregnancy BMI was 24.5±5.2, 21% were overweight (BMI 25 – 29.9), 15% were obese (BMI>30). Mean weight gain was 15.6 ± 6.6 kg. Overall, 14% had preeclampsia and 1% gestational diabetes. Mean birth
weight was 3154±435g. Controlling for the above covariates (except diabetes), only maternal weight gain and preeclampsia were independent predictors of birth weight. A maternal weight gain of 1 kg corresponded to
an average of 25g greater birth weight (p<0.001). On average, infants born to women with preeclampsia weighed 151g less (p= 0.02). Infants of women who smoked averaged 142g less (p=0.10).
CONCLUSIONS: Weight gain during pregnancy but not pre-pregnancy BMI predicted birth weight in teen pregnancy. Preeclampsia independently predicted birth weight; smoking appeared to be associated with lower
birth weight.
Filename: 753931
Presenting Author: Chintan Gandhi, MD
Phone: 732 745 8523
Fax:
Title: Compliance with Appropriate Duration of Antibiotic Therapy in NICU and Its Effect on Necrotizing Enterocolitis and Nosocomial Infections
Chintan Gandhi1, Diane Chiappi1, Mark Hiatt1 and Shakuntala Chandra1. 1Division of Neonatology, Department of Pediatrics, Saint Peters University Hospital, New Brunswick, NJ.
BACKGROUND: Virtually all low birth weight infants admitted to NICU receive empirical antibiotic treatment in the first postnatal days and is based on the immaturity of these infants' immune systems, the high
mortality rate among infants who have invasive bacterial infections and higher prevalence of Early Onset Sepsis (EOS) among preterm infants compared with term infants. One of the challenges for clinicians is
discontinuing antimicrobial therapy once sepsis is deemed unlikely
Authors
Conclusion
Cordero and Ayeres et al
No advantage of longer empirical antibiotic courses was apparent
Cordero etal
Discontinuing empiric antibiotics when blood cultures are negative in asymptomatic ELBW infants can reduce antimicrobial
exposure without compromising clinical outcome
Bizzaro et al
Duration of antibiotic factor is an independent risk factor for NEC and is associated with increased risk of NEC among neonates
without prior sepsis
Kuppala et al
Prolonged administration of empirical antibiotic treatment is associated with increased rates of NEC and death for ELBW
infants
Cotton et al
Prolonged duration of initial empirical antibiotic therapy is associated with increased rates of NEC and death for ELBW infants
OBJECTIVE: To identify number of preterm infants ≤ 1500gm infants who were exposed to longer duration of antibiotics and improve compliance of antibiotic therapy to 3 days. Effect of antibiotic duration on NEC and
nosocomial infections
DESIGN/METHODS: To meet our objectives we educated the care takers to discontinue antibiotics when cultures were negative for 48 hours,use declining CRP as a guide to discontinue antibiotics.In culture negative
patients If infants were asymptomatic with normal lab data antibiotics were discontinued despite maternal risk factors, use antibiotics judiciously to reduce the cumulative antibiotic exposure
We compared 2 similar groups of preterm infants one before and after implementation of these practices
RESULTS: Our compliance with ≤ 3 days of antibiotic therapy reduced from 42% to 66%(p=0.3),cumulative antibiotic days from a mean of 4.75 ± 5.1 to 3.91 ± 4.7 days (p=0.2 )NEC from 7% to
4.3%(p=0.6),nosocomial infections from 3.5to 3.2% (p=0.9)
CONCLUSIONS: By education we improved our compliance with ≤ 3 days of antibiotic therapy we showed improving trends with reduced cumulative antibiotic days, NEC and nosocomial infections
Filename: 750015
Presenting Author: Christina M. Freiberger
Department/Institution/Address: 20 Concord Drive, S. Walpole, MA, 02071, United States
Phone: United States
Fax:
Title: Epidemiology of Apnea, Bradycardia, and Desaturation in Late Preterm and Full Term Infants
Christina M. Freiberger1, Lauren Veit1,2, Sagori Mukhopadhyay3 and Lawrence M. Rhein1,4. 1Division of Newborn Medicine, Boston Children's Hospital, Boston, MA; 2University of Massachusetts Medical School,
Worcester, MA; 3Newborn Medicine, Brigham and Women's Hospital, Boston, MA and 4Divison of Respiratory Diseases, Boston Children's Hospital, Boston, MA.
BACKGROUND: Apnea, bradycardia, and oxygen desaturations (ABDs) in late preterm (PT) and full term (FT) infants are underdescribed in the literature. Since these infants make up the largest portion of live births,
even a low percentage affected is significant. ABDs may result in prolonged lengths of stay (LOS), so identification of associated traits may allow development of better treatment strategies.
OBJECTIVE: To describe the prevalence of ABDs in the late PT and FT infant, and to identify factors associated with prolonged LOS in these infants.
DESIGN/METHODS: We conducted a retrospective review of late PT and FT infants at 2 large tertiary care institutions, for whom ABDs were the last remaining discharge criteria. Infants were included if they (a) were
inborn at either hospital from 2009-13 at a gestational age (GA) ≥34 0/7 weeks, and (b) had a documented event of ABD within 6 days of discharge as the final discharge-delaying diagnosis.
RESULTS: Prevalence of ABD in our cohort was 1.8% (n=1077). As expected, prevalence decreased with increasing GA at birth.
Infants with a LOS ≥ 14 days after full feeding maturity were more likely to have a lower GA, receive caffeine, and be sent home with a monitor.
We were unable to identify additional specific demographic traits that predicted longer LOS (≥ 14 days).
CONCLUSIONS: While ABDs affect a significant number of late PT and FT infants, there are no specific variables that predict their LOS. Further studies to determine optimal management of discharge-delaying
ABDs in this population are warranted.
Filename: 750374
Presenting Author: Amruta Bamanikar, MD
Department/Institution/Address: Pediatrics, 4422 3rd Avenue, Bronx, NY, 10457, United States
Phone: 6128608604
Fax: 7189609418
Title: Maternal Third Trimester Bmi Is Associated With Late Term Birth and Neonatal Morbidity
Amruta Bamanikar1, Ronald Arevalo1,2, Cecilia Godoy1, Jeffrey Le1, Megan Kaknis1, Paulo Pina1,2 and David Rubin1,2. 1Pediatrics, St. Barnabas Hospital, Bronx, NY and 2Albert Einstein School of Medicine, Bronx, NY.
BACKGROUND: Studies have shown that increasing pre-pregnancy maternal body mass index (BMI) is associated with early gestational age (GA). Even in full term infants, early term [37(0/7)-38(6/7) weeks, days]
have higher morbidity compared to late term babies [39(0/7)-41(6/7) weeks, days]. However, there is limited data on the association between maternal third trimester BMI (BMI-3), GA at birth and neonatal
complications.
OBJECTIVE: To determine the relationship between of BMI-3, gestational age at birth and neonatal morbidity in term infants.
DESIGN/METHODS: Retrospective chart review of maternal and neonatal data extracted from medical records of all early and late term newborns between May - November 2013 at a University affiliated, inner city
community hospital. Twin pregnancies, missing BMI-3, extramural deliveries and GA at birth determined by methods other than first trimester ultrasound were excluded. Statistical analysis included bivariate and
multivariate methods.
RESULTS: 467/600 (77%) deliveries met study inclusion criteria. 15.2 % of mothers had normal BMI-3 (18.5-24.9), 31.3% were overweight (25-29.9), 24% were Class I (30-34.9), 18.2% were Class II (35-39.9) and
11% were morbidly obese (>40). 31% were early term and 69% were late term births. BMI-3 was significantly associated with GA at birth, maternal gestational complications and birth weight. Using multivariate
regression, there was a dose-dependent increase in the odds of delivering a late term neonate with increase in BMI-3. GA at birth was, however, not associated with neonatal complications. Being overweight was
significantly associated with neonatal complications such as resuscitation at birth, hypoglycemia, respiratory distress, suspected sepsis and hyperbilirubinemia (OR= 1.15 CI[0.26-0.34]). We did not find an increase in
cesarean section rates.
CONCLUSIONS: These data suggest that as maternal third trimester BMI increases, the odds of being delivered late term increase - independent of mode of delivery. There was a general trend towards neonatal
complications with increasing BMI-3 above 25 kg/m2. Our study did not show increased neonatal morbidity among early term births. This has implications on obstetrical care and close follow-up of women with higher
BMI as this increases the risk of neonatal morbidity in term newborns.
Filename: 751745
Presenting Author: Dina D. Daswani, MD
Department/Institution/Address: Pediatric Emergency Medicine Department, The Children's Hospital at Montefiore, Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, United States
Phone: 718-644-9192
Fax: 718-798-6485
Title: Accuracy of Point-of-Care Lung Ultrasound for Diagnosis of Acute Chest Syndrome in Pediatric Patients with Sickle Cell Disease and Fever
Dina D. Daswani1, Vaishali P. Shah2, Jeffrey R. Avner1, Deepa G. Manwani3, Jessica Kurian4 and Joni E. Rabiner1. 1Pediatric Emergency Medicine Department, The Children's Hospital at Montefiore, Montefiore
Medical Center, Bronx, NY; 2Pediatric Emergency Medicine Department, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, NJ; 3Pediatric Hematology-Oncology Department, The
Children's Hospital at Montefiore, Montefiore Medical Center, Bronx, NY and 4Pediatric Radiology Department, The Children's Hospital at Montefiore, Montefiore Medical Center, Bronx, NY.
BACKGROUND: Acute Chest Syndrome (ACS) is a major cause of morbidity and mortality in patients with sickle cell disease (SCD) that usually requires chest X-ray (CXR) as part of routine standard of care. Lung
ultrasound (LUS) is useful in the diagnosis of pulmonary pathology and can be performed accurately by clinicians.
OBJECTIVE: To determine the accuracy of point-of-care LUS performed by pediatric emergency medicine (PEM) physicians compared to radiographic diagnosis of ACS in patients with SCD and fever.
DESIGN/METHODS: This was a prospective study of patients < 21 years with SCD presenting to the emergency department with fever requiring CXR for evaluation of ACS. Patients were excluded for CXR within 5
days or diagnosis of ACS within 6 weeks. Prior to the start of the study, PEM physicians received a one-hour didactic and hands-on training session on LUS. Before obtaining CXR, a PEM physician blinded to the
clinical history and physical examination performed LUS using a linear 10-5 MHz transducer probe using a standardized scanning protocol. A positive LUS for ACS was defined as the enrolling PEM physician's
determination of lung consolidation with air bronchograms. All patients received CXR and clinical telephone and electronic medical record follow-up. The gold standard for ACS in this study was defined as infiltrate,
consolidation, pneumonia, or effusion on CXR as determined by a blinded radiologist, with equivocal CXRs reviewed by a blinded pediatric radiologist. LUS clips were reviewed by a blinded expert PEM sonologist.
RESULTS: One hundred febrile events from 80 patients with a mean age of 6 (+/-4.6) years were enrolled by 14 PEM sonologists. 13 (13%) had a CXR positive for ACS; LUS was positive for ACS in 17 (17%). A
positive LUS had a sensitivity of 92% (95% CI: 67-99%), specificity of 94% (95% CI: 87-98%), positive likelihood ratio of 16.1 (95% CI: 6.8–38.2), and negative likelihood ratio of 0.08 (95% CI: 0.01–0.54) for ACS. Two
equivocal CXRs were reviewed for a final diagnosis. There was 1 missed ACS on LUS due to operator error identified on blinded expert LUS review.
CONCLUSIONS: Point-of-care LUS is highly sensitive and specific for diagnosis of ACS in pediatric patients with SCD and fever. LUS may reduce the need for routine CXR and associated ionizing radiation exposure
in this population.
Filename: 750791
Presenting Author: Nishit Patel, MD
Department/Institution/Address: 100 Hepburn Road, Apt # 8A, Clifton, NJ, 07012, United States
Phone: 708-921-1786
Fax:
Title: The Practice of Obtaining a Chest X-ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians
Nishit Patel1, Ameer Hassoun1 and Jennifer Chao1. 1Pediatric Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY.
BACKGROUND: Routine use of Chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not
routinely indicated in these children, there continues to be reports of overuse.
OBJECTIVE: To identify the current practice and factors that influence obtaining a CXR in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) in the United States.
DESIGN/METHODS: A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3,000 members of the PEM Brown
listserve and the American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and
current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and Chi-square test.
RESULTS: Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine and 4% other. 72% of participating physicians supervise residents, 54%
were board eligible or certified (be/bc) in PEM. 30% (95% confidence interval [CI]: 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of
wheezing. 81% (95% CI: 75-87) of those who always obtain a CXR believe that it is standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI: 15-23) always obtain a CXR under certain
age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were be/bc in PEM, and who were practicing for greater than 5 years were less
likely to obtain a CXR (p<0.001, p<0.001, p<0.001, p=0.006).
CONCLUSIONS: 30% of physicians routinely obtain a CXR in pediatric patients presenting to the ED with their first episode of wheezing, most of them believe it is standard of care. The factors influencing this practice
are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in
pediatric patients with wheezing.
Filename: 755240
Presenting Author: Anna Weingarten, D.O.
Department/Institution/Address: Department of Pediatrics, University of Connecticut Health Center, 161 Sterling Dr, Newington, CT, 06111, United States
Phone: 9082473049
Fax:
Title: What Is “Asthmonia”?
Anna Weingarten1, Christine H. Mulvey2 and Sharon R. Smith2. 1Department of Pediatrics, University of Connecticut Health Center, Farmington, CT and 2Department of Emergency Medicine, Connecticut Children's
Medical Center, Hartford, CT.
BACKGROUND: Asthma and pneumonia are two common conditions encountered in the pediatric emergency department (PED). Many clinicians recognize the overlapping clinical presentation of pneumonia and
asthma. The overlap and treatment is not well described in the literature.
OBJECTIVE: The aim of our study is to determine the prevalence and describe the clinical characteristics of children with asthma who also meet commonly accepted criteria for pneumonia. The term “asthmonia” is a
colloquial term used in many PEDs to describe the combination of asthma and pneumonia.
DESIGN/METHODS: A retrospective chart review of children, age 2-17 years, presenting to an urban PED between January 1, 2012 and December 31, 2012 was conducted. Patients were admitted with a primary
diagnosis of asthma or pneumonia. "Asthmonia" was defined as 1) documentation of wheezing, 2) administration of bronchodilator, 3) history of asthma, 4) chest radiograph with radiologist interpretation consistent
with pneumonia, and 5) administration of antibiotics. Acute severity was defined by validated severity measure (MPIS) ranging from 0 to 18. Children with significant comorbidities were excluded. Children with
"asthmonia" were compared to children with asthma or pneumonia alone. Charts were audited for demographic characteristics, asthma severity, admission to inpatient or critical care unit, radiographs, and antibiotics.
Mann-Whitney U test and frequency counts were used for statistical analysis.
RESULTS: A total of 461 children were admitted with diagnosis of either asthma or pneumonia. Of those 366 (79%) were eligible for analysis and 64(17.5%) met criteria for asthmonia. Patients had a mean age of 6.1
(SD = 3.9) with the majority being males (56%) presenting to the PED with a respiratory complaint (81%). Children with asthmonia were significantly younger than children with asthma (p < .05). There were no
significant differences in MPIS and admission to the ICU between groups. However, frequency data indicated that asthmonia patients had both higher MPIS and ICU admissions than either asthma or pneumonia
patients.[table]
CONCLUSIONS: In this cohort, the coexistence of pneumonia and asthma or "asthmonia" was present in almost 20% of admitted children. These children tend to be younger and have more severe asthma than
children with asthma alone. More studies are needed to better elucidate this clinical entity and the indications for antibiotics.
Table 1.
Asthmonia (n=64) Asthma (n=239) Pneumonia (n=61)
Age
6.5 (3.93)*
5.45 (4.13)
MPIS 9.5 (7-12)
5.39 (3.62)*
9 (8-11)
N/A
PICU 6 (9%)
19 (8%)
3 (5%)
* p<.05
Filename: 753969
Presenting Author: Bai Yi Ted Chen, BS
Department/Institution/Address: 229 University Manor East, Hershey, PA, 17033, United States
Phone: 5107598048
Fax:
Title: A Comparison of Analgesic Administration Between Pediatric and Adult Trauma Patients Presenting to an Emergency Department in Central Pennsylvania
Bai Yi Ted Chen1, Alina Schmidt1, Nisha Hariharan1 and Robert Olympia1. 1Emergency, Pennsylvania State University Hershey College of Mediicine, Hershey, PA.
BACKGROUND: Previously published studies have shown that pediatric patients are less likely to receive treatment for pain compared to adult patients presenting with similar chief complaints. The misconception that
infants and children do not feel pain and the fear of iatrogenic consequences are possible factors contributing to oligoanalgesia in pediatric patients.
OBJECTIVE: To determine whether trauma-activated pediatric patients presenting to an emergency department in central Pennsylvaniareceive analgesic treatment as part of their initial evaluation compared to adult
patients.
DESIGN/METHODS: A retrospective review of patients presenting as trauma activations to the Penn State Hershey Medical Center between 6/2011 and 6/2013 was performed. Patients who were Level 1 trauma
activations, who initially were treated at another institution and then transferred, and who were treated with analgesics by emergency medical services en route were excluded. Administration of analgesics was
stratified by age (pediatric patients < 18 years), mechanism of injury, initial Injury Severity Score (ISS), and diagnosis.
RESULTS: Data analysis was performed on 1254 patients (153 pediatric/1101 adult). When adjusted for initial ISS, adult patients received analgesics more often than pediatric patients (odds ratio 2.7). When stratified
by mechanisms of injury and diagnosis, a smaller percentage of pediatric patients received analgesics for falls [32% (95% CI:18-50) vs. 65% (95% CI:59-70)], head injuries [32% (95% CI:23-44) vs. 71% (95%
CI:67-75)], facial injuries [45% (95% CI:33-57) vs. 71% (95% CI:67-75)], and thoracic injuries [26% (95% CI:10-48) vs. 83% (95% CI:79-86)] compared to adult patients. When stratified by initial ISS, pediatric patients
were less likely to receive analgesics compared to adult patients at ISS 1-10 [58% (95% CI:48-67) vs. 72% (95% CI:68-76)], ISS 11-20 [51% (95% CI:35-67) vs. 78% (95% CI:74-82)], ISS 21-30 [41% (95% CI:18-65)
vs. 79% (95% CI:74-85)], and ISS > 30 [25% (95% CI:3-71) vs. 87% (95% CI:79-94)].
CONCLUSIONS: Our data demonstrates that pediatric patients presenting as trauma activations received less analgesics during their initial evaluation compared to adult patients, with statistically significant
differences for falls, head and facial injuries, thoracic injuries, and various levels of initial ISS.
Filename: 751312
Presenting Author: Erin Hulfish, MD
Department/Institution/Address: Critical Care, AI duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE, United States
Phone: 703-862-4131
Fax:
Title: The Impact of a Displayed Checklist on Pediatric Trauma Resuscitations
Erin Hulfish1, Glenn Stryjewski1, Maria Carmen G. Diaz1, Heather Sobolewski1, Heather Kulp1, Megan Feick1 and Emily Murphy1. 1Nemours AI duPont Hospital for Children, Wilmington, DE.
BACKGROUND: The Advanced Trauma Life Support (ATLS) protocol has helped to standardize a trauma patient evaluation in a time efficient manner. However, the protocol is not always well-followed, which can
lead to missed steps of the exam, communication error, and overall more time spent performing primary and secondary surveys with subsequent delays in care. Checklists have been shown to improve communication
between team members and reduce error.
OBJECTIVE: The primary goal of this study is to determine if a displayed checklist, visible to all team members, improves time to completion of tasks during pediatric trauma resuscitations. The secondary purpose of
this study is to determine if a displayed checklist improves the absolute completion of tasks of the primary and secondary survey.
DESIGN/METHODS: 45 scenarios were created following ATLS core competencies. The study was broken into three arms: one without a checklist; one with the team leader utilizing a handheld paper checklist; and
one with the checklist displayed on a monitor visible to all team members. Each scenario was recorded then evaluated by two investigators to ensure reliability for time to completion and absolute completion of tasks.
RESULTS: There have been 16 scenarios completed to date. There is an absolute reduction of time with both the checklist displayed and handheld. In evaluating between the displayed versus handheld scenarios,
the displayed checklist reduced the time of completion of both the primary and secondary survey.
Average Primary Survey Completion Time (sec)
Average Secondary Survey Completion Time (sec)
Average Time to Log Roll (sec)
Average Secondary Survey Missed Elements
Control
67
176
172.73
4.64
Handheld List
83
295
232.67
0.33
Displayed List
68
210
167.3
5.6
There was a significant decrease in tasks missed when the checklist was utilized versus no checklist, 3.4 vs 4.4 respectively.
CONCLUSIONS: The use of a checklist during trauma resuscitation has been shown to improve adherence to ATLS protocols. With the ability to have all members of the resuscitation team able to see the checklist,
there is a reduction in both the time to completion of the secondary survey as well as completion of tasks. We believe this will improve team communication as well as performance during resuscitation.
Filename: 751856
Presenting Author: Katie A. Donnelly, MD
Department/Institution/Address: Emergency Department, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20011, United States
Phone: 2024764177
Fax:
Title: Patients at High Risk for Intervention for Pediatric Traumatic Liver Injury
Katie A. Donnelly1 and Karen O'Connell1. 1Emergency Medicine, Children's National Medical Center, Washington, DC.
BACKGROUND: Non-operative management of hemodynamically stable liver lacerations is a safe and effective management strategy for pediatric patients; approximately 90% will be successfully managed
non-operatively. No study has specifically identified risk criteria for the need for intervention versus observation alone.
OBJECTIVE: To determine risk factors from the physical examination, CT scan, and laboratory results associated with intervention for liver laceration.
DESIGN/METHODS: We performed a retrospective cohort study using data from the public use dataset from the Pediatric Emergency Care Applied Research Network (PECARN) Intra-abdominal Injuries Study. Data
were collected prospectively at the time of enrollment; a limited data set was released for public use in 2014. Patients were included if they were diagnosed with a liver laceration by CT scan. We used bivariable and
multivariable analyses to determine associations of specific risk factors with intervention, defined as laparotomy, angiographic embolization, blood transfusion, death or return to emergency department within 30 days.
RESULTS: Of the 12,044 patients in the IAI study, 282 were diagnosed with a liver laceration. All patients were hospitalized, and 99 (35.1%) underwent an intervention. Variables were then eliminated if more than
10% of cases were missing data. Multivariable logistic regression identified the following independent risk factors for intervention: white blood cell count greater than 15 (adjOR 2.83, 95% CI 1.43, 5.63), pelvic fracture
(adjOR 2.50, 1.02, 6.10) , liver injury greater than Grade 2 (adjOR 2.1.58 1.06, 4.405), Glasgow Coma Scale less than 15 (adjOR 4.77, 2.27, 10.04, 7.63) and hematocrit less than 32 (adjOR 4.787, 2.00, 11.46).
CONCLUSIONS: We identified five high risk criteria associated with intervention for traumatic liver laceration. Prospective studies will be important to validate these results before using them to determine disposition
of patients.
Filename: 753482
Presenting Author: A. Fiks
Department/Institution/Address: 334 Winding Way, Merion, PA, 19066, United States
Phone: 2674262304
Fax:
Title: A Practice-Based Randomized Trial of a Shared Decision Making Portal in Childhood Asthma
A. Fiks1, S. Mayne1, D. Karavite1, A. Suh1, R. Localio1, M. Ross1 and R. Grundmeier1. 1The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Electronic health record (EHR)-linked patient portals are a promising approach to facilitate shared decision making (SDM) between families of children with chronic conditions and pediatricians.
OBJECTIVE: To evaluate the feasibility, acceptability, and impact of MyAsthma, an EHR-linked patient portal supporting SDM for pediatric asthma.
DESIGN/METHODS: We conducted a six-month randomized controlled trial of MyAsthma at three primary care practices. Families were randomized to MyAsthma, which tracks families' asthma treatment concerns,
children's asthma symptoms, medication side effects and adherence, and provides decision support, or to standard care. Outcomes included the feasibility and acceptability of MyAsthma for families, child healthcare
utilization and asthma control, and the number of days of missed school (child) and work (parent). Acceptability was assessed through open-ended responses. Descriptive statistics and longitudinal regression models
assessed differences in outcomes between the study arms.
RESULTS: We enrolled 60 families, 30 in each study arm (88% completed followup). 57% of parents in the intervention group used MyAsthma during at least 5 of the 6 study months. Parents of children with moderate
to severe persistent asthma used the portal more than others. Among all users, 92% were satisfied with MyAsthma. Parents reported that use improved their communication with the office, ability to manage asthma,
and awareness of the importance of ongoing attention to treatment. Trends toward improvement with MyAsthma use were observed for nearly all outcomes, including increased controller medication prescriptions,
fewer ED visits and fewer hospitalizations. Parents in the intervention group reported that children had a lower frequency of asthma flares (p=0.02) and intervention parents missed fewer days of work due to asthma
(p=0.001).
Intervention (N (%) with ≥1)
Control (N (%) with≥1)
Intervention (count per child) Control (count per child)
N=26 children
N=27 Children
Hospitalizations
0 (0%)
1 (4%)
0
0.07
ED Visits
2 (8%)
6 (22%)
0.1
0.3
Asthma Specialist Visits
8 (31%)
12 (44%)
0.4
0.8
18 (67%)
1.1
1.5
Visit Type
Primary Care Asthma Visits 16 (62%)
Medication Prescriptions
Inhaled Steroids
18 (69%)
17 (63%)
1.2
0.7
Oral Steroids
7 (27%)
11 (41%)
0.4
1.1
CONCLUSIONS: Use of an EHR-linked asthma portal was feasible and acceptable to families and improved clinically meaningful outcomes.
Filename: 753061
Presenting Author: Marissa Hauptman, MD, MPH
Department/Institution/Address: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, 300 Longwood Ave, BCH 3114, Boston, MA, 02115, United States
Phone: 917.239.9691
Fax: 617-355-0049
Title: Residential and School Proximity To Major Roadways and Asthma Morbidity in the School Inner-City Asthma Study
Marissa Hauptman1,2, Jonathan M. Gaffin3, Carter R. Petty2,4, Diane R. Gold5 and Wanda Phipatanakul2,5. 1Division of General Pediatrics, Boston Children's Hosptial, Boston, MA; 2Division of Allergy and Immunology,
Boston Children's Hospital, Boston, MA; 3Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA; 4Clinical Research Center, Boston Children's Hospital, Boston, MA and 5Division of Respiratory
Epidemiology, Channing Laboratory, Brigham and Women's Hospital, Boston, MA.
BACKGROUND: Traffic related air pollutants are associated with deleterious effects on respiratory health. Scant research exists exploring asthma morbidity attributable to near-roadway school air quality.
OBJECTIVE: To use spatial analysis to analyze school and residential proximity to major roadways and pediatric asthma morbidity.
DESIGN/METHODS: School Inner-City Asthma Study (n=351) recruited children with asthma, ages 5 to 13, from more than 30 schools between 2009 - 2013. Primary caregivers completed baseline questionnaires
detailing medical history, asthma morbidity, secondhand smoke exposure, and sociodemographic characteristics. These children also underwent anthropometrics and pulmonary function tests (PFTs) at baseline and
subsequent follow–up visits. Major roadways were defined as U.S. Census primary and secondary roadways. We geocoded school and home addresses, measuring their respective distance to major roadways in
meters. Using multivariate logistic regression analyses, baseline asthma morbidity was compared between children residing or attending school within the closest quartile to major roadways versus those in the farthest
3 quartiles.
RESULTS: In multivariate analyses, children attending school in the nearest quartile to major roadways have 2.8 (95% CI: 0.8 -9.5) times the odds of being hospitalized for asthma over previous 12 months as
compared to those in farthest 3 quartiles (p < 0.09). Participants attending school and residing in the nearest quartile have 2.9 (95% CI: 1.2 - 6.6) times the odds of spirometry results suggestive of small airway
disease (FEF25-75 less than 80% predicted) as compared to those in farthest 3 quartiles (p < 0.02).
CONCLUSIONS: Attending school nearest to major roadways is associated with higher asthma hospitalization rates; residing and attending school nearest to major roadways is associated with increased markers of
small airway disease. Subsequent analyses will include longitudinal data and school air quality measurements.
Filename: 750485
Presenting Author: John Rausch, MD MPH
Department/Institution/Address: Pediatrics, Columbia University, 622 West 168th Street, VC 417, New York, NY, 10032, United States
Phone: 2123421917
Fax: 212 3058819
Title: Evaluating the Impact of IT Tools To Support the Asthma Medical Home
John Rausch1, L. Adriana Matiz1, Laura Robbins-Milne1, M. Christine Krause1 and Patricia J. Peretz2. 1Pediatrics, Columbia University, New York, NY and 2Ambulatory Care Network, NewYork Presbyterian Hospital,
New York, NY.
BACKGROUND: Establishing a “medical home” for children with asthma is one means of improving health outcomes. As a medical home model of care is implemented, innovative IT tools can improve care
coordination and disease management as well as supply many of the elements necessary for population management.
OBJECTIVE: The aim of this study is to evaluate the impact of innovative IT tools in the care of children with asthma in 4 large, urban academic pediatric practices as a medical home model of care was implemented.
DESIGN/METHODS: A disease registry was established of all children ages 4-18 with an ICD-9 code for asthma (493.XX) as of August 2010. Changes to the EHR included modifications to the provider notes with an
asthma section prompting guideline-based classification, control assessment and risk stratification. An asthma care plan was built with medications and goal setting. A referral order for community health worker care
coordination was created and prompts for completion of medication forms for school administration of beta-2 agonists were added. A retrospective analysis was conducted of the emergency department (ED) and
in-patient utilization for a cohort of patients from July 2009 through June 2013 who were patients of the medical homes during the study period (n=1217). Student t-tests were used to calculate differences in number of
ED visits and in-patient admissions for asthma between baseline and year three using SAS 9.3.
RESULTS: Of the study population, 65% of children had a classification of asthma severity and 63% were risk-stratified by year 3. Seventy percent had a control assessment at least once during the study period. Care
plan use increased four-fold and enrollment to the care coordination program increased 50-fold. After the first three years of using these tools, there was a reduction of both ED and in-patient admissions for asthma
that were statistically significant (p<0.05 and p<0.005 respectively).
CONCLUSIONS: The implementation of IT tools in the EHR supported process changes which led to improved quality of care and patient outcomes for patients with asthma. Tools included a registry, prompts for risk
stratification, assessment of control, streamlining referrals for care coordination, care plans with goals and prompts for coordination with schools. Implementation of these types of IT tools to care for patients with
chronic conditions will be essential as medical home models are adopted.
Filename: 755820
Presenting Author: Jamie M. Pinto, MD
Department/Institution/Address: Department of Pediatrics, Jersey Shore University Medical Center, 1945 Route 33, Neptune, NJ, 07753, United States
Phone: 1-732-776-4267
Fax: 1-732-776-2344
Title: Factors Associated With Duration of Hospitalization in Children With Non-Severe, Acute Bronchiolitis
Jamie M. Pinto1, Janet L. Schairer1 and Anna Petrova1,2. 1Pediatrics, Jersey Shore University Medical Center, Neptune, NJ and 2Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
BACKGROUND: Acute bronchiolitis is a self-limited, viral respiratory infection in young children that results in hospitalization for observation and supportive therapy when moderate to severe respiratory distress,
deoxygenation, or dehydration are present.
OBJECTIVE: This study was designed to evaluate the length of stay (LOS) of hospitalized children less than 2-years old with mild to moderate bronchiolitis with respect to demographic, clinical and treatment
variables.
DESIGN/METHODS: Medical records of 195 hospitalized patients with bronchiolitis, without evidence of pneumonia or congenital/chronic respiratory conditions were studied. Multivariate models were created to
identify the impact of age, clinical severity of disease, oxygen saturation (SpO2%), administration of nebulized therapies (albuterol, 27.2%; albuterol + 3% saline, 19.5%; 3% saline alone, 16.9%; or no inhaled
treatment, 36.4%) and inclusion of other treatments, such as corticosteroids (4.6%), antibiotics (27.7%) and/or oxygen (27.2%) on LOS. Data is presented as regression coefficient (β) +/-Standard Error (Sdt.Er) of β.
RESULTS: We found that respiratory score on admission and use of corticosteroids had no impact on LOS in children with bronchiolitis. A significant and direct association was identified between LOS and use of 3%
saline treatment alone (0.152+/-0.067) or in conjunction with albuterol (0.271+/-0.066), whereas duration of hospitalization was shorter with no inhaled treatment (-0.183+/-0.061) or use of albuterol alone
(-0.199+/-0.069), independently of other factors. LOS increased with hypoxia on admission and oxygen supplementation during hospitalization and decreased with age and antibiotic use (P<0.05-0.01).
CONCLUSIONS: Prolongation of hospitalization of children with non-severe bronchiolitis is associated with younger age, hypoxia at admission, supplemental oxygen and nebulized therapy with hypertonic saline.
Filename: 752904
Presenting Author: Manuel Jimenez, MD
Department/Institution/Address: Pediatrics, Rutgers Robert Wood Johnson Medical School, 89 French St, Rm 1349, New Brunswick, NJ, 08901, United States
Phone: 732-235-6188
Fax:
Title: A Pilot Randomized Trial of a Video Decision Aid To Facilitate Early Intervention Referrals
Manuel Jimenez1,2, Nathalie DuRivage3, Andrew Suh3, Orysia Bezpalko3, Nathan Blum3 and Alexander Fiks3. 1Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; 2Children's Specialized
Hospital, New Brunswick, NJ and 3Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Many children identified with developmental concerns in the medical home do not receive early intervention (EI).
OBJECTIVE: To assess the impact of a video decision aid and text message reminder on EI knowledge, attitudes, intention to pursue EI and referral outcomes.
DESIGN/METHODS: Randomized controlled trial
Subjects/Setting:Parent child dyads from 2 urban pediatric clinics were eligible if the child was identified with a developmental concern, was <36 months, and not receiving EI and if primary language at home was
English
Intervention:A video decision aid explaining developmental delay, EI, and the referral process shown at the visit and an SMS text message reminder sent 7-14 days later. The decision aid was developed with parent
and clinician stakeholders based on international standards. We used sealed envelopes for allocation concealment prior to randomization.
Outcomes:Parent reported attitudes and knowledge regarding developmental delay and EI and intention to pursue EI. EI intake and evaluation based on parent report and/or chart review.
Analysis:We used Wilcoxon signed rank test to test attitudes and knowledge change among subjects within arms and chi square analysis to test difference in intention, EI intake and evaluation across arms.
RESULTS: 64 subjects were randomized(31 intervention, 33 control). Baseline characteristics were similar across arms(77% of children <24 mos, 88% of parents African American, 57% ≤high school diploma).
Intervention parents' knowledge of developmental delay and EI increased compared to controls. For example, the percentage of intervention subjects who agreed or strongly agreed with the statement “A child who
takes longer to talk, walk, or think may have developmental delay,” increased from 25 to 45%(p=0.01). We detected no significant difference in pre and post attitudes in either arm or the percentage of parents who
intended to pursue EI across arms. EI intake and evaluation information was available for 59/64 dyads. 77% completed intake in the intervention arm(20/26) compared to 64% in the control arm(21/33). 65% completed
EI evaluation in the intervention arm(17/26) compared to 52% in the control(17/33). These differences were not statistically significant.
CONCLUSIONS: In our sample, a video decision aid and text message intervention improved parent knowledge regarding developmental delay and EI with a trend toward increasing EI intake and evaluation.
Filename: 751544
Presenting Author: Stacy Ellen, DO
Department/Institution/Address: Pediatrics, St. Christopher's Hospital for Children, 160 East Erie Ave., Philadelphia, PA, 19134, United States
Phone: 2022476864
Fax: 2154276014
Title: The Feasibility of a Positive Parenting Text Message Program in an Inner-City Pediatric Clinic
Stacy Ellen1,2, Falguni Patel3, Bruce Bernstein1,2, Maria McColgan1,2 and Lee Pachter1,2. 1Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA; 2Drexel University College of Medicine, Philadelphia, PA
and 3Drexel University School of Public Health, Philadelphia, PA.
BACKGROUND: The pediatrician's role includes identifying risk factors for toxic psychosocial stressors, giving parents anticipatory guidance in discipline, educating on negative effects of physical punishment, and
referring at risk families to appropriate community resources. Common parenting and discipline education venues include well child visits, evidence-based parenting programs and community parenting groups.
However, parents often do not look to pediatricians for parenting advice during visits and low-income families often cannot access or attend parenting groups due to a variety of factors. Text messaging, however, is
ubiquitous and its use is increasing in healthcare.
OBJECTIVE: This study aims to investigate the feasibility of implementing a text message-based positive parenting and discipline program for an inner city pediatric clinic population.
DESIGN/METHODS: A cross-sectional anonymous survey was administered in English and Spanish to parents and caregivers of 0-5 year-old children in clinic waiting rooms in a north Philadelphia children's hospital.
The 23-item survey assessed parents'/caregivers' cell phone usage, text messaging practices and desire to receive parenting and discipline advice.
RESULTS: Of the 258 respondents, 96% have a cell phone and 95.2% have unlimited monthly text messages. Less than half (39%) reported wanting parenting and discipline advice from doctors. While only 19% of
parents desire parenting classes, 45% would prefer parenting and discipline advice via text message. Age, race, ethnicity, education, employment status, cell phone service type and text message frequency were not
predictive of parental desire to receive advice through a text message program. Caregivers and parents of children ages 12 to 24 months were more likely to desire parenting advice, as compared to parents of infants.
CONCLUSIONS: This feasibility study demonstrated that an intervention implemented via a text-message platform is likely acceptable in this population. A text-message program delivering advice to parents may be
preferred over face-to-face discussions with a pediatric physician. A follow-up qualitative study will be conducted to determine parenting and discipline themes, frequency of texts and wording desired. Allowing parents
in our community to contribute to the creation of the messages themselves will likely lead to higher salience and acceptance of a text message-based parenting education program.
Filename: 753019
Presenting Author: Meredith L. Monaco-Brown, MD
Department/Institution/Address: Pediatrics, Division of Neonatology, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, United States
Phone: 518-262-5421
Fax: 518-262-5881
Title: Pilot Translational Study: Utility of Neuroantibody (NAb) Biomarkers in Hypoxic-Ischemic Encephalopathy (HIE)
Meredith L. Monaco-Brown1, Dana Price1, Michael J. Horgan1 and Hassan A. El-Fawal2. 1Pediatrics, Division of Neonatology, Albany Medical College, Albany, NY and 2Neurotoxicology, Albany College of Pharmacy
and Health Sciences, Albany, NY.
BACKGROUND: HIE has devastating neurological outcomes. With a narrow window of intervention and no accurate diagnostic modality, the development of high throughput biomarkers may address this challenge.
Preclinical studies suggest that neuroimmune interactions with nervous system (NS)-specific antigens provide a record of insult in the form of NAb.
OBJECTIVE: Delineate the humoral detection of NAb biomarkers and their association with clinical parameters in newborns with HIE.
DESIGN/METHODS: Sera from 9 neonates with HIE (under therapeutic hypothermia) and 5 control neonates were collected within the first 24h of birth and at 48h. Neonates were ≥35 wk gestation and ≥10th %ile
weight. Additional sera was collected at 72h (n=7) and at 7d (n=5) from the HIE group. Titers of IgM and IgG against neurofilaments (NF), glial fibrillary acidic protein (GFAP) and myelin basic protein (MBP) were
measured using ELISA. Parametric and non-parametric statistics were used to compare groups and for associations with Apgar scores, EEG, and MRI.
RESULTS: NAb of the IgM class against all NS proteins, except NF-L, were found in most neonates at 24 and 48h. However, those of HIE neonates tended to be higher than the collective median, with anti-NF-M
being significantly (p<0.001) higher in HIE. NAb titers in only HIE neonates at 24, 48 and 72h significantly and inversely associated (r=-0.6 to-0.9; p<0.001-0.01) with at least one of the Apgar scores, with the strongest
and most frequent associations being for anti-NF-M. For anti-MBP, IgM, titers at 48h and later inversely (r=-0.9; p<0.02) associated with Apgar scores and directly associated with EEG and MRI scores (r=0.6; p<0.03).
CONCLUSIONS: This preliminary data from an ongoing study of HIE suggests that NAb, particularly against NF-M and MBP, are associated with pathophysiological events in neonates. Early NAb detection supports
the further validation of their clinical utility as plausible objective biomarkers of HIE and other NS insults in children.
Filename: 752897
Presenting Author: Juhye Lena Kim, MD
Department/Institution/Address: The Regional NICU, Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, United States
Phone: 9144938558
Fax: 9144935049
Title: Recurrent Hypoglycemia Affects the Post-Transcriptional Regulation of the Adrenal Tyrosine Hydroxylase (TH) Gene
Juhye Lena Kim1,2, Necla Kudrick1,2, Edmund F. La Gamma1,2 and Bistra Nankova2. 1Division of Newborn Medicine, Departments of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla,
NY and 2Division of Newborn Medicine, Departments of Pediatrics, Biochemistry and Molecular Biology, New York Medical College, Valhalla, NY.
BACKGROUND: A recent exposure to hypoglycemia can cause defective counterregulation in healthy humans and animal models leading to Hypoglycemia Associated Autonomic Failure (HAAF) during subsequent
episodes. The molecular mechanisms underlying HAAF are not well understood.
OBJECTIVE: We hypothesized that the impaired epinephrine release following recurrent hypoglycemia may arise from the reduced ability to produce catecholamines by the adrenal medulla.
DESIGN/METHODS: Normal, adult male rats with vascular catheters placed were randomly assigned to 4 different groups (n ≥ 6), and were given insulin (2 IU/kg) or saline injection once per day (recurrent
hypoglycemia - RH, recurrent saline - RS) or twice per day (2RH and 2RS, respectively) for 3 days. The blood glucose levels were maintained between 40-50mg/dL. On day 4, the animals were sacrificed at 0, 30 and
60 min or 3 hour after a 90 min-hypoglycemic hyperinsulinemic clamp. Blood samples were collected at 30 min intervals throughout the day 4 experiments for the measurement of plasma counter regulatory hormones,
glucagon and epinephrine, to assure proper implementation of the animal models. Western blot analysis was used to quantify the changes in the amount of Ser 40-phospho TH (a marker of TH enzyme activation,
which is the rate limiting enzyme in catecholamine biosynthesis), total TH protein, activation of protein kinase A (PKA) signaling and unfolded protein response.
RESULTS: The epinephrine and glucagon responses were attenuated in the 2RH group as expected. This was associated with a lack of accumulation of adrenal TH protein. The changes in TH phosphorylation status
were transient and not detectable by 5 hrs after initiation of insulin infusion in all experimental groups. While similar activation of PKA signaling and TH phosphorylation initially occur following both, acute (RS and 2RS
groups) and recurrent (RH and 2RH groups) insulin-induced hypoglycemia, TH enzyme in the 2RH group was inactivated much more rapidly. Together, our novel findings indicate reduced adrenal capacity to produce
catecholamines in HAAF.
CONCLUSIONS: We show for the first time, that novel post-transcriptional mechanisms regulating the translation and the turnover of the activated adrenal TH enzyme may contribute to the impaired epinephrine
responses in HAAF. A better understanding of these underlying mechanisms may afford the discovery of new therapeutic targets to prevent HAAF.
Filename: 752635
Presenting Author: Uday Patil, MD
Department/Institution/Address: Division of Neonatology, Department of Pediatrics, Formerly NYU School of Medicine and Currently Elmhurst Hospital Center, Mt., Elmhurst Hospital Center, 79-01 Broadway,
Department of Pediatrics, Division of Neonatology, Elmhurst, NY, 11373, United States
Phone: 001-405-778-9519
Fax:
Title: Serum Biomarkers of Neuronal Injury in Newborns Who Where Evaluated for Hypoxic Ischemic Encephalopathy But Did Not Qualify for Head Cooling, Compared To Normal Newborns: A Pilot
Study
Uday Patil1, Pradeep Mally2 and Elena Wachtel2. 1Division of Neonatology, Department of Pediatrics, Formerly NYU School of Medicine and Currently Elmhurst Hospital Center, Mount Sinai School of Medicine,
Elmhurst, NY and 2Division of Neonatology, Department of Pediatrics, New York University School of Medicine, New York, NY.
BACKGROUND: Evaluation of newborns for Hypoxic Ischemic Encephalopathy (HIE) undergoing Head Cooling (HC) includes laboratory and clinical parameters, neurological examination as well as amplitude
integrated EEG. Based on these criteria, some newborns do not qualify for HC. Biomarkers of neuronal injury may be helpful to confirm that these newborns in fact had not sustained brain injury.
OBJECTIVE: To assess levels of serum Glial Fibrillary Acidic Protein (GFAP), Ubiquitin C-terminal Hydrolase-1 protein (UCHL-1) and Phosphorylated axonal Neurofilament Heavy chain (pNF-H) in newborns who met
initial screening criteria, but did not qualify for HC and compare them to healthy newborns.
DESIGN/METHODS: This is an IRB approved prospective study conducted from July 2013 through June 2014 at NYU Langone medical center and Bellevue Hospital Center Neonatal Intensive Care Units and
newborn nurseries. Newborns ≥ 36 weeks gestational age, who were evaluated but did not qualify for HC, were enrolled. Healthy newborns from regular nursery were enrolled as control group. Serum samples were
collected between 24-48hrs of life from both groups.
RESULTS: 26 subjects were enrolled including 11 consecutive newborns evaluated for HC and 15 controls from regular nursery. The mean gestational age and birth weights were not significantly different between the
groups. As expected, median APGAR scores at 1 and 5 minutes, umbilical cord or initial postnatal arterial blood gas pH and base deficit were significantly different (p=<0.05). Comparison of biomarkers of brain injury
between these 2 groups did not yield statistically significant difference.
Background
pNF-H
UCHL-1
GFAP
Group
Mean (+Std. Deviation) pg/dl P-Value
Controls
143.72 (+71.72)
Evaluated
170.58 (+114.29)
Controls
161.59 (+129.24)
Evaluated
130.40 (+145.50)
Controls
34.76 (+23.14)
Evaluated
65.41 (+56.19)
0.469
0.570
0.099
CONCLUSIONS: In our pilot study, we found that newborns excluded from HC did not show significant elevation of biomarkers of brain injury when compared to healthy newborns. This may suggest that these
newborns did not sustain significant neuronal injury to cause encephalopathy and thus, validating the current evaluation criteria for HC.
Filename: 752842
Presenting Author: Kashish Mehra
Department/Institution/Address: Dept. of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, 245 N. 15th Street, New College Building, MS 1029, Philadelphia, PA, 19141,
United States
Phone: 215-762-7515
Fax: 215-762-7960
Title: Effects of Hypoxic-Preconditioning on AIF-Mediated Apoptotic Pathway in Hypoxic-Ischemic Piglet Model
Kashish Mehra1, Tahlar McIntosh2, Maria Delivoria-Papadopoulos2 and Jahan Ara2. 1Dept. of Pediatrics, Albert Einstein Medical Center, Philadelphia, PA and 2Dept. of Pediatrics, Drexel University and St.
Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Activation of caspase-dependent or caspase-independent apoptosis represents a hallmark of hypoxia-ischemia induced neuronal cell death. Hypoxic-preconditioning (PC) is known to protect against
apoptosis, but the molecular mechanisms that underlie its protective actions are not clear. We have previously demonstrated the protective efficacy of PC against hypoxic-ischemic (HI) injury in newborn piglet model.
In this study, we sought to determine the molecular mechanisms underlying the anti-apoptotic effects of preconditioning.
OBJECTIVE: The objective of this study was to determine the contribution of apoptosis-inducing factor (AIF), a major factor for caspase-independent mediated cell death pathway, to hypoxic-ischemic injury in
newborn piglet brain and to determine whether PC prevents the AIF release and its nuclear translocation.
DESIGN/METHODS: Piglets were divided into three groups: (I) normoxia (NX), piglets were subjected to 21% O2; (II) hypoxia-ischemia (HI), piglets were subjected to a combination of hypoxia (5% FiO2) for 30
minutes and ischemia by a 10 minute period of hypotension; (III) preconditioning+hypoxia-ischemia (PC+HI), piglets were subjected to 8% oxygen for 3h, reoxygenated for 24h and then subjected to HI. All groups
were recovered for 24h, 3 days or 7 days. After recovery, piglets were anesthetized, and brains were harvested for subcellular fractionation and Western blot analysis.
RESULTS: Western blot analysis of the nuclear fractions of hypoxic-ischemic brain samples revealed a significant elevation of translocated nuclear AIF levels. In the normoxic brain, AIF expression in nuclear fractions
was significantly lower at 24h, 3 days and 7 days of recovery. AIF translocation to the nucleus occurred 24h after HI and significantly increased at 3 days and 7 days after HI compared to normoxic controls. On the
other hand, preconditioning performed 24h prior to severe HI attenuated the AIF translocation into the nucleus at 3 days of recovery.
CONCLUSIONS: These findings suggest that AIF plays a role in hypoxic-ischemic cell death and that inhibition of the translocation of AIF may attribute to the neuroprotective activity of preconditioning.
Filename: 752843
Presenting Author: Sharina Rajbhandari
Department/Institution/Address: Department of Pediatrics, Albert Einstein Medical Center, 5500 Old York Road, Philadelphia, PA, 19141, United States
Phone: 215-762-7515
Fax: 215-762-7960
Title: Effect of Hypoxic-Preconditioning on AIF Mitochondrial-Nuclear Translocation in Newborn Piglet Brain
Sharina Rajbhandari1, Tahlar McIntosh2, Geoffrey Bajwa2, Maria Delivoria-Papadopoulos2 and Jahan Ara2. 1Dept. of Pediatrics, Albert Einstein Medical Center, Philadelphia, PA and 2Dept. of Pediatrics, Drexel
University and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Features of both caspase-dependent and caspase-independent apoptotic cell death are recapitulated experimentally in the neonatal brains of animals subjected to hypoxia-ischemia. Many studies
suggest that caspase-independent apoptotic cell death mechanisms may contribute significantly to ischemic injury. One critical signaling molecule is apoptosis inducing factor (AIF), which can be released from
mitochondria in response to oxidative stress. Exposure to mild hypoxia (preconditioning) confers protection against apoptosis, but molecular mechanisms of this protective efficacy require further elucidation.
OBJECTIVE: The objective of this study was to evaluate the effects of hypoxia-ischemia and preconditioning subsequent to hypoxia-ischemia on expression of apoptosis inducing factor (AIF) in mitochondria and
nucleus.
DESIGN/METHODS: Piglets were divided into three groups: (I) normoxia (NX), piglets were subjected to 21% O2; (II) hypoxia-ischemia (HI), piglets were subjected to a combination of hypoxia (5% FiO2) for 30
minutes and ischemia by a 10 minute period of hypotension; (III) preconditioning+hypoxia-ischemia (PC+HI), piglets were subjected to 8% oxygen for 3h, reoxygenated for 24h and then subjected to HI. All groups
were recovered for 24h, 3 days or 7 days. After recovery, piglets were anesthetized, perfused transcardially, and brain sections were processed for immunohistochemistry.
RESULTS: We analyzed the cellular distribution of AIF by immunohistochemistry in brain sections obtained at 24h, 3 days and 7 days after HI and PC+HI. In normal brains, AIF showed extranuclear, i.e., cytoplasmic
staining that colocalized with COX (cytochrome c oxidase subunit IV), a mitochondrial marker. In sections from HI brains at 3 and 7 days of recovery, a large number of cells in the cortex showed AIF
immunofluorescence with a nuclear localization (co-staining with Hoechst), confirming the nuclear translocation of AIF. In contrast, the occurrence of cells with nuclear AIF translocation was greatly decreased in
PC+HI newborn brains at 3 and 7 days of recovery compared to HI brains.
CONCLUSIONS: These findings suggest that AIF-related caspase-independent pathway is an essential target of preconditioning-mediated neuroprotection.
Filename: 752457
Presenting Author: Emmanuelle Topiol
Phone: 215-762-7515
Fax: 215-762-7960
Title: Effect of Hypoxia on Second Mitochondria-derived Activator of Caspase (Smac) Protein in the Cytosolic Fraction of the Cerebral Cortex of Newborn Piglets
Emmanuelle Topiol1, Panagiotis Kratimenos1, Amit Jain1, Shadi Malaeb1 and Maria Delivoria-Papadopoulos1. 1Department of Pediatrics, Drexel University and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Second mitochondria-derived activator of caspases/direct inhibitor of apoptosis-binding protein with a low isoelectric point (Smac/DIABLO) is the second mitochondrial protein that activates apoptosis.
Smac/DIABLO is released concurrently with cytochrome c from mitochondria into the cytosol during apoptosis. Smac/DIABLO re-activates the initiator and effector caspases by relieving the inhibitor of apoptosis
protein (IAP)-mediated inhibition, neutralizes IAP fucntion.
OBJECTIVE: The present study tests the hypothesis that hypoxia results in increased expression of Smac/DIABLO in the cytosolic compartment of a cell in the cerebral cortex of the newborn piglets.
DESIGN/METHODS: Newborn piglets were randomly assigned to two groups: normoxic (Nx, n=2) and hypoxic (Hx, n=4). The normoxic group was exposed to an FiO2 of 0.21 for 1 hr. The hypoxic group was exposed
to an FiO2 of 0.07 for 1 hr. Tissue hypoxia was documented biochemically by determining the levels of ATP and phosphocreatine (PCr). The cytosolic fractions from cortex were isolated and proteins were separated
by Western blotting and probed with an antibody specific for Smac/DIABLO. Protein bands were detected by enhanced chemiluminescence and the optical density was expressed as OD/mm2.
RESULTS: ATP (µmoles/g brain) was 4.4±0.4 in Normoxic and 1.57±0.3 in Hypoxic group (p<0.05 vs Hx). PCr (µmoles/g brain) was 3.5±0.2 in Normoxic and 1.3±0.3 in Hypoxic group (p<0.05 vs Hx). Western blot
analysis showed that hypoxia increased the expression of Smac/DIABLO in the cytosolic fractions of the cerebral cortex. Density of Smac/DIABLO protein was 214.57±37.39 in Normoxic and increased to
474.53±52.28 in Hypoxic group (p<0.05 vs Nx).
CONCLUSIONS: We propose that hypoxia disrupts mitochondrial membrane integrity and causes the leak of apoptosis inducing proteins into the cytosol. We suggest that hypoxia-induced increase in Smac/DIABLO
will activate programmed cell death in the newborn piglet brain. The increased level of Smac/DIABLO protein during hypoxia indicates that hypoxic cell death in the piglet brain is mediated by a caspase-dependent
mechanism.
Filename: 753127
Presenting Author: Abigael Maxwell, MD
Department/Institution/Address: The Regional NICU, Maria Fareri Children's Hospital, Westchester Medical Center-NYMC, 100 Woods Road, Valhalla, NY, 10595, United States
Phone: 203-507-9093
Fax:
Title: The Impact of Exclusive Breastmilk Diet on Growth and NEC
Abigael Maxwell1, Amy Abraham1, Rhonda Valdes-Greene1, David Aboudi1, Heather Brumberg1, Edmund LaGamma1 and Boriana Parvez1. 1The Regional NICU, Maria Fareri Children's Hospital, Westchester Medical
Center-NYMC, Valhalla, NY.
BACKGROUND: Exclusive human milk diet with mother's own or donor milk enriched with human milk derived fortifier (Prolact+H2MF) has been advocated for ELBW infants to lower rates of necrotizing enterocolitis
(NEC). Preterm neonates fed formula or breast milk and cow milk fortifier (Enfamil® HMF) demonstrate faster growth. Concerns of slower growth than the "reference fetus" have been raised as extrauterine growth
restriction (EUGR) may lead to reprograming, development of metabolic syndrome and adversely affect neurodevelopment.
OBJECTIVE: To compare growth velocity (g/week, GV) and NEC in ELBW infants fed breast milk (BM) fortified with either Prolact+H2MF (Prolacta) or Enfamil® HMF (HMF).
DESIGN/METHODS: Case-control study of ELBW matched for GA±1wk, BW±100g and disposition (home/transfer) fed BM with either Prolacta or HMF, comparing GV, NEC, ROP, IVH (grade 3/4), PVL, BPD and
PCA (post-conceptual age at disposition) at the following time points: T0 birth, T1 time of max weight loss, T2 regain BW, T3 fortifier start, T4 fortifier stop, T5 disposition. We report T0-T5 comparisons. Χ2, Fisher's
exact and t-test were used with p<0.05 indicative of significance.
RESULTS: 24 infants were included in each group, with similar BW, GA and major NICU morbidities, including NEC.
All
Prolacta
HMF
Number of patients
48
24
24
GA (wks, mean±SD; range)
26±2; 23-29
26±2; 23-29
26±2; 23-29
BW (grams, mean±SD; range) 807±171; 480-1100 792±183; 480-1100 823±160; 580-1100
Male Gender %
35
46
25
SGA %
2
4
0
C-section %
50
58
42
BPD %, n
55, 24/44
67, 16/24
40, 8/20 (4 d/c <36 wks)
Grade 3/4 IVH %
17
8
25
PVL %
13
8
17
Severe ROP %
8
4
13
Late onset sepsis %
4
0
9
NEC %
8
13
4
In the Prolacta group, discharge weight (DW) and GV were larger (3351±880g vs 2739±953g, p=0.03 and 169±22 vs 149±33 g/week, p=0.01, respectively). Mean DW centile in both groups was lower than BW
centile. The mean centile difference between BW and DW was significantly smaller in Prolacta group, 22 vs 39 point drop, p=0.029. The rate of EUGR (DW<10%) in the Prolacta group was 17% (4/23 infants,
excluding 1 SGA at birth) vs 29% (7/24) in the HMF group, p=0.49.
CONCLUSIONS: Contrary to previous reports our patients fed exclusive human milk diet had better growth and similar NEC rates. Followup is needed to demonstrate the long term benefits of improved growth.
Filename: 753155
Presenting Author: Christine Ennis, MD
Department/Institution/Address: Neonatology, 4745 Ogletown Stanton Rd MAP 1, suite 217, Newark, DE, United States
Phone: 302-733-2410
Fax:
Title: Do VLBW Infants on an Exclusive Fortified Human Milk Diet Achieve Adequate Growth?
Christine Ennis1,2, Deborah Tuttle1,2, Haritha Vellanki1, Amy Mackley1 and Robert Locke1,2. 1Neonatology, Christiana Care Health System, Newark, DE and 2Neonatology, Sidney Kimmel Medical College/Thomas
Jefferson University, Philadelphia, PA.
BACKGROUND: An exclusive human milk (EHM) diet is associated with reduced necrotizing enterocolitis (NEC). In 2010, Christiana Hospital implemented a protocol to provide an EHM diet to very low birth weight
(VLBW) infants, using maternal and donor milk, fortified with a human milk derived fortifier, until reaching 1800g or 34 weeks post conceptual age. This intervention decreased NEC. The impact on growth, an
important balancing measure, is presented here.
OBJECTIVE: Define the incidence and risk factors for growth <10 g/kg/day in VLBW infants fed an EHM diet.
DESIGN/METHODS: Dieticians recorded weekly growth on VLBW infants post implementation of EHM diet protocol. Infants with growth <10 g/kg/day (LG) for 1 week, on 150 ml/kg/day feedings fortified with a 4
cal/ounce human milk based fortifier were targeted for intervention to improve weight gain. Infants with adequate growth (AG) were continued on standard fortification. Birth weight (BW), gestational age (GA), small for
gestational age (SGA), SNAP scores, ventilator days, type of human milk (donor or maternal) and growth were collected. LG infants were compared to AG infants using multivariate analysis.
RESULTS: 198 infants (mean BW 953g ±221, mean GA 27.1 wks ±1.8) from 10/2010 to 10/2013 were included in the analysis. 57% of the infants received only fortified donor milk (DM), 27% received only fortified
maternal milk (MM) and 16% received both (MDM). BW, GA, SGA, SNAP scores and ventilator days were not different between the groups and were not significant risk factors for LG except for BW. Overall, 32% of
infants had LG. 44% in the DM group had LG, compared to 17% in the MM and 16% in the MDM groups. Multivariate analysis demonstrated DM feedings and BW to be significant risk factors for LG. Controlling for
BW, DM feedings remained a significant risk factor for LG (table1). 69% of LG infants had escalation of fortification (>4 cal/oz), which improved growth in 93%.
p-value OR for adequate growth* 95% CI
DM
<.001
-
-
MDM
.007
4.373
1.507-12.693
MM
<.001
4.577
1.974-10.613
*Controlling for Birth Weight
CONCLUSIONS: VLBW infants exclusively fed 4 cal/oz fortified DM are at risk for LG compared to infants fed 4 cal/oz fortified MM. Strategies to track DM use and to maximize MM supply should be integral to an
EHM diet initiative. Growth can be adequate when using DM, but enhanced fortification may be necessary.
Filename: 753923
Presenting Author: Jessica Davidson, MD
Department/Institution/Address: Pediatrics, Tufts Medical Center, Division of Newborn Medicine, 800 Washington Street, Box 44, Boston, MA, 02111, United States
Phone: 617-636-5322
Fax:
Title: Optimal Timing and Sex Specific Responses To Olfactory Stimulation with Mother's Own Milk To Decrease the Time To Full Oral Feeds in Premature Infants
Jessica Davidson1, Jooyeon S. Hwang2, Mallory Kosow2 and Jill L. Maron1,2. 1Pediatrics, Tufts Medical Center, Boston, MA and 2Mother Infant Research Institute, Tufts Medical Center, Boston, MA.
BACKGROUND: Oral feeding maturation is a major contributor to length of stay for the premature newborn. Previous studies have shown that olfactory stimulation with a maternal scent, i.e. mother's own breast milk
(MOM), expedites successful oral feeding.
OBJECTIVE: To determine optimal timing and sex specific responses to olfactory stimulation with MOM to shorten time to full oral feeds (FOF) in preterm infants
DESIGN/METHODS: This was a prospective, placebo-controlled, single-center, randomized study. Infants born between 28 0/7 and 33 6/7 weeks' gestational age (GA) to breast feeding mothers were consented.
Each mother provided a sample of fresh breast milk (≤ 30 mL) that was aliquoted and frozen at -80°C. Infants were randomized within the first week of life to olfactory stimulation with water (sham) or MOM. Stimulus
was held 2 cm from the nares for 15 minutes during an enteral feed, once a day, for at least 4 days a week until transfer to a Level II nursery or attainment of FOF. Statistical analyses included paired t tests comparing
sham vs. MOM groups and males vs. females, as well as a one-way ANOVA to understand the impact of MOM olfactory stimulation at varying GA.
RESULTS: Thirty infants were included in this study: 28 to 29 6/7 weeks' GA (n=8); 30 to 31 6/7 weeks' GA (n=13); and 32 to 33 6/7 weeks' GA (n=9). Combined, infants who received sham intervention obtained FOF
at an earlier post menstrual age (PMA) compared to infants with MOM stimulation (sham PMA 35 2/7 weeks vs. MOM PMA 36 weeks; p = 0.05). However, when stratified for GA, infants born at the earliest GA who
received MOM stimulation reached full oral feeds at a younger PMA compared to controls (sham PMA 36 weeks, MOM PMA 35 2/7 weeks; p =0.2). Younger GA females (28 to 29 6/7 weeks) stimulated with MOM
achieved FOF at an earlier PMA compared to older GA females (ANOVA p = 0.07). There was no difference in males (ANOVA p = 0.55).
CONCLUSIONS: In this pilot study, the data suggest that there is an optimal time in development and sex specific responses to olfactory stimulation to improve oral feeding skills. Infants born < 30 weeks' GA appear
to benefit most; females are impacted more than males. Timely intervention with stimulation of MOM in these infants may provide a personalized and noninvasive strategy to expedite oral feeding skills and reduce
length of stay.
Filename: 751750
Presenting Author: Khaled M. Abdelrahman
Department/Institution/Address: Department of Bioengineering, University of Pittsburgh, 321 Coltart Ave, Pittsburgh, Pennsylvania, 15213, United States
Phone: 9316449738
Fax:
Title: Optimizing Fat Delivery Methods in Continuous Enteral Feeding of Expressed Breast Milk To Neonates
Khaled M. Abdelrahman1,2, Amy B. Hair1, Keli M. Hawthorne1 and Steven A. Abrams1. 1Department of Pediatrics, USDA/ARS Children's Nutrition Research Center, Baylor College of Medicine, Section of Neonatology,
Texas Children's Hospital, Houston, TX and 2Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA.
BACKGROUND: Accurate delivery of fat is critical for growth of premature infants, as fat accounts for ~55% of the energy content of human milk. Previous studies have shown that delivery of expressed breast milk
(EBM) by enteral feeding results in fat losses of 15% to 40%. These losses are attributed to milk fat globules (MFGs) left behind in the syringe and to adhesion of MFGs to nasogastric (NG) tubing used for delivery.
OBJECTIVE: To evaluate methods of improving fat retention in enteral feeding systems using a simulated continuous feeding.
DESIGN/METHODS: Using a simulated syringe pump enteral feeding system, pooled EBM delivered through a Medfusion pump and NG tubing was collected in aliquots at 20 min intervals for 1 hr. Fat content of
EBM aliquots were compared to baseline fat content to determine fat retention over the course of the feed. The syringe was tested with the syringe tip in horizontal, up and down orientations. Mechanical agitation was
used to gently agitate EBM during simulated feeds. Feeds of EBM at 5 mL/hrand 15 mL/hrwere investigated, as well as short NG tubing (42”) and extended tubing (102”). Studies were repeated with EBM mixed with
human milk-derived fortifier (HMF).
RESULTS: Fat retention using 6.5 F NG tubing at 5 mL/hr infusion rate compared to baseline fat content was significantly improved with the syringe nozzle pointed up compared to the horizontal and down orientations
(94.8% vs 78.6% vs 60.9% fat retention, p<0.05). The agitation mechanism demonstrated (91.4% vs. 78.6%, p<0.05) improvement in fat retention at 5 mL/hr. Fat retention increased at higher flow rates, and
decreased with longer tubing at high infusion rates. When EBM was fortified with HMF, fat retention was improved compared to plain EBM.
CONCLUSIONS: Maintaining a homogenous emulsion by mixing EBM in the syringe, orienting the syringe nozzle facing up, using faster flow rates, and using shorter tubing improved fat retention. These strategies
should be considered as tolerated by the infant in order to ensure that critical fat from EBM is delivered to the infant for growth.
Filename: 751148
Presenting Author: Patoula G. Panagos, MD
Department/Institution/Address: Pediatric Newborn Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN 418, Boston, Massachusetts, 02115, United States
Phone: 6175254129
Fax:
Is Presenting Author a Trainee? Yes, Other - Research Assistant
Title: Maternal Dietary Quality Affects Breast Milk Composition
Patoula G. Panagos2, Annie Penfield-Cyr1, Nitin Shivappa3, Michael D. Wirth3, James R. Hebert3 and Sarbattama Sen1. 1Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA; 2Pediatric
Neonatology, Nemours A. I. duPont Hospital for Children/Thomas Jefferson University Hospital, Wilmington, DE and 3Epidemiology and Biostatistics, University of South Carolina, Columbia, SC.
BACKGROUND: We have previously shown that breastmilk (BM) of obese (Ob) mothers has a pro-inflammatory fatty acid (FA) profile. Nutrition provided in infancy has a profound impact on obesity risk in offspring.
Maternal diet, through changes in BM composition, could also impact offspring growth. Here we use a literature-derived population-based Dietary Inflammatory Index (DII), a predictor of dietary inflammatory potential,
to determine whether BM composition is influenced by modifiable maternal dietary factors.
OBJECTIVE: To examine the relationship between maternal DII, BM composition and infant growth.
DESIGN/METHODS: BM was collected 4-10 weeks post-partum from 21 lean (BMI 18-25kg/m2) and 21 Ob (BMI>30kg/m2) women. These samples were analyzed for micronutrient and macronutrient composition.
Food diaries were collected and specific food parameter estimates were used to calculate a DII for each subject. A higher DII score indicates a pro-inflammatory diet. Infant growth was obtained at the same time point.
RESULTS: Ob women had a higher DII (p=0.059). BM from Ob mothers had a higher omega (n)-6:n-3 FA ratio (p<0.01) compared to lean mothers. The DII was strongly positively correlated with BM saturated FA
(R=0.46, p<0.01), and strongly negatively correlated with BM n-3 FA (R= -0.46, p<0.01). BM n6:n3 was positively correlated with infant z-score (R=0.43, p<0.05). These relationships remained significant after
adjustment for maternal BMI.
CONCLUSIONS: Our study suggests that maternal diet is a major modifiable factor that affects the inflammatory composition of BM.
Filename: 754858
Presenting Author: Daniel Ruderfer, MD
Department/Institution/Address: Pediatrics, Winthrop-University Hospital, 259 First St, Mineola, NY, 11501, United States Minor Outlying Islands
Phone: 011-516-663-2288
Fax: 011-516-663-8955
Title: Increased Bilirubin Readmissions Associated With Changes in Breast Feeding Rate
Daniel Ruderfer1,2, Smitha Mathew1,2, Alena Connelly1,2, Kalgi Mody1,2 and Warren Rosenfeld1,2. 1Pediatrics, Winthrop-University Hospital, Mineola, NY and 2Pediatrics, State University of New York at Stony Brook,
Stony Brook, NY.
BACKGROUND: Hyperbilirubinemia is the most frequent cause of pediatric readmissions. Monitoring the incidence of hyperbilirubinemia readmissions and determining the factors associated with their increase or
decrease, may be helpful in their prevention.
OBJECTIVE: The objective of the present study was to measure the incidence of readmissions for hyperbilirubinemia and determine possible contributing factors.
DESIGN/METHODS: All readmissions for hyperbilirubinemia from 2009-2013 were reviewed. Only readmissions from the Winthrop-University Hospital well baby nursery were included (NICU admissions were
excluded). Analysis included gestational age, predischarge bilirubin (BR), type of feeding [breast exclusive (BM); breast & formula (B/F); formula only (F)], hours of discharge, type of delivery, sex, race, and universal
screening.
RESULTS: Over the 5 years of analysis, there were a total of 19,693 births that met criteria for analysis. The rates of readmission from 2009-2011 were 0.96%, 0.67% and 0.87% respectively and significantly
increased (<0.001)* to 1.22% in 2012 and to 1.88% in 2013. The rate of readmissions doubled over the 5 years of this study. There was no change in the rate of readmissions with the implementation of universal
screening in 2010 or other factors analyzed. The increased rates of readmission were associated with an increased rate of exclusive breast feeding which rose from 6% in 2009 and 2010 to 25%, 35%, and 41% in the
subsequent years.
YEAR # BIRTHS # BR READM % READM HOSP % EXCLUSIVE BM % READM EXCLUSIVELY BM % READM BM or B/F
2009 3841
37
0.96
6
19
84
2010 3897
26
0.67
6
38
81
2011 3898
34
0.87
25
27
80
2012 3848
47
1.22*
35
49
87
2013 4209
79
1.88*
41
37
88
CONCLUSIONS: Over the last 5 years our rate of readmissions for hyperbilirubinemia has doubled from baseline (p <0.001) and was associated with a marked increase in the rate of breast feeding in our nurseries.
Breast feeding initiatives are necessary and strategies to prevent hyperbilirubinemia in this group need to be developed and utilized. These findings also suggest early and close followup of breast fed babies is
necessary.
Filename: 750055
Presenting Author: Elizabeth W. Tucker, MD
Department/Institution/Address: 101 S. Ellwood Ave, Apt 326, Baltimore, MD, 21224, United States
Phone: 336-816-3756
Fax:
Title: A Rabbit Model To Study the Pathogenesis of Pediatric Central Nervous System Tuberculosis
Elizabeth W. Tucker1, Supriya Pokkali2, Zhi Zhang1, Elizabeth Nance1, Courtney Robertson1, Sanjay Jain2 and Sujatha Kannan1. 1Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD and
2
Pediatrics, Johns Hopkins Hospital, Baltimore, MD.
BACKGROUND: Central nervous system (CNS) Tuberculosis (TB) is a devastating disease that disproportionately affects young children. A better understanding of its pathogenesis will lead to development of novel
therapies. Our hypothesis is that CNS TB infection in the developing brain will lead to an intense pro-inflammatory microglial response and that host-directed treatments directed toward activated microglia could lead
to novel treatments for this devastating disease.
OBJECTIVE: To determine if CNS TB in juvenile rabbits leads to neuroinflammation mediated by activated microglia resulting in injury to the brain and long-term neurobehavioral deficits
DESIGN/METHODS: Rabbits were chosen due to the similarity in their brain development to human myelination and microglial presence. The neuroinflammatory response following exposure to live Mycobacterium
tuberculosis (Mtb) H37Rv of different multiplicity of infection was determined in -1) BV-2 microglial cells, 2) ex vivo rabbit brain slices and 3) in vivo rabbit kits, 4-7 days old [corresponds to toddler age]. Activated
microglia were detected in vivo by PET imaging using the specific tracer [11C] DPA-713 and in vitro with immunohistochemistry. Neurobehavior was compared between infected and control groups.
RESULTS: Initial in vitro and ex vivo studies determined the optimal dosing to demonstrate neuroinflammation. BV-2 cells exposed to Mtb showed a dose-dependent response, with a 1000 fold increase in TNF-α
levels compared to controls at the highest infecting dose (MOI 1:50). Exposure of ex vivo brain slices to Mtb resulted in increased microglial clumping and change in morphologyin a dose-dependent manner both at
MOI of 1:50 and 1:10. In vivo intraparenchymal administration of MOI 1:10 led to a robust increase in microglial numbers and change in morphology to an amoeboid, activated phenotypes as early as 24 hours
post-infection. In vivo subarachnoid administration of Mtb led to granuloma formation in the brain and lungs 14 days post-infection. This was associated with delayed maturation and impaired locomotion.
CONCLUSIONS: We have developed a pediatric model of CNS TB that demonstrates intense microglial activation in the brain, granuloma formation and is associated with neurological deficits, as seen in children.
Therapies targeted to activated microglia may help attenuate this injury.
Filename: 750276
Presenting Author: Birju A. Shah, MD MPH
Department/Institution/Address: Pediatrics, Women and Infants' Hospital of Rhode Island, The Alpert Medical School, 101 Dudley Street, Providence, Rhode Island, 02905, United States
Phone: 401-284-1122 x 47442
Fax: 401-453-7571
Title: Inter-alpha Inhibitor Protein Is Superior To C-reactive Protein as a Biomarker To Differentiate Necrotizing Enterocolitis from Spontaneous Intestinal Perforation
Birju A. Shah1, Paula Krueger1, Yow-Pin Lim1, Surendra Sharma1 and James Padbury1. 1Pediatrics, Women and Infants Hospital, The Alpert Medical School of Brown University, Providence, RI.
BACKGROUND: Inter-alpha inhibitor proteins (IAIP) are natural serine protease inhibitors that play a crucial role in modulating host response to inflammatory insults. Serum IAIP levels are significantly reduced in
neonatal sepsis and necrotizing enterocolitis (NEC). Currently, there is no biomarker is available to differentiate NEC from spontaneous intestinal perforation (SIP), serious morbidities affecting preterm infants.
OBJECTIVE: To compare plasma levels of IAIP to those of CRP in infants with NEC, SIP and matched controls.
DESIGN/METHODS: Prospective observational unmasked study. Blood samples were collected at onset of symptoms from infants diagnosed with NEC, SIP and matched controls admitted to NICU of Women and
Infants Hospital of RI. Infants with NEC were diagnosed by Bell's staging criteria (all had ≥ stage 2 or 3). Infants with SIP were diagnosed by clinical and radiological findings. Infants in the control group had
non-specific abdominal disorders but no radiographic evidence of NEC or SIP and no disease progression. Controls were matched for gestational age, gender and weight. Plasma IAIP and CRP levels were quantified
using competitive enzyme-linked immunosorbent assay. Mean biomarker levels were subjected to analysis of variance (ANOVA) and post-hoc analysis.
RESULTS: There were 28 infants studied in three groups.
Varibale
NEC (n=5) SIP (n=6) Controls (n=17) P-value
Gestational age, weeks*
275±34
264±15
Age at presentation, days* 12.2±11.5 8.1±4.8
275±26
0.64
10.2±7.1
0.11
Birth weight, grams*
1025±705 825±243 1067±570
0.69
Gender, male %
20%
66%
0.25
IAIP at onset, µg/ml*
139 ± 21
319 ± 72 276 ± 110
0.01
CRP atonset, ng/ml*
18.4± 24.9 15.8± 9.6 6.9± 14.2
0.27
35%
*Mean±SD
Plasma IAIP levels were significantly lower in infants with NEC at onset when compared to those with SIP and matched controls (p<0.004 and p<0.01 respectively). In contrast, plasma CRP levels were not different
among infants with NEC, SIP and matched controls at disease onset (P 0.27).
CONCLUSIONS: As a biomaker, IAIP may assist in early detection of NEC from controls and differentiate NEC from SIP at disease onset. IAIP has higher discrimination than that of CRP. This differentiation at
disease onset may lead to earlier effective treatments and improved outcomes.
Filename: 750143
Presenting Author: Christopher G. Manschreck
Department/Institution/Address: 50 Allen St Apt 8, Buffalo, NY, 14202, United States
Phone: 6172332050
Fax:
Title: Escherichia coli Inhibition by Commensal Bacteria of the Female Genital Tract
Christopher G. Manschreck1 and Betsy C. Herold1. 1Dept of Pediatrics, Albert Einstein College of Medicine, Bronx, NY.
BACKGROUND: Vaginal Escherichia (E.) coli colonization is observed in ~10% of healthy women and is associated with recurrent urinary tract infections (UTI). During pregnancy, E. coli colonization is associated with
chorioamnionitis, preterm birth, very low birth weight and neonatal sepsis. Healthy vaginal microbiota may contribute to host defense against E. coli colonization. Several studies have shown that vaginal secretions
from healthy women exhibit innate inhibitory activity against E. coli ex vivo, whereas secretions from women with bacterial vaginosis have reduced inhibitory activity.
OBJECTIVE: To test the hypothesis that soluble products from Lactobacillus (L.) crispatus and L. jensenii, but not Gardnerella (G.) vaginalis, contribute to innate host defense against E. coli.
DESIGN/METHODS: L. jensenii strain 62G, L. crispatus strains 60, M35, and SJ-3C and G. vaginalis strains 594 and AmMS 177 were grown and spent culture supernatants (SCS) isolated by centrifugation and
0.2µm cellulose acetate filtration. 100µL SCS or 100µL control broth were incubated in duplicate with 10^7 cfu E. coli in a 96 well plate. Optical density was calculated from absorbance at 620nm recorded over time.
Additional experiments were conducted with dilutions of SCS adjusted to pH 6.5 and to the same protein concentration. To further assess the potency of the SCS, 5 x 10^5 cfu of E. coli were incubated with dilutions of
SCS and grown on culture plates for 24h.
RESULTS: Results of the 96-well assay are presented in Table 1:
Species and strain
L. crispatus 60
L. crispatus SJ-3C
L. crispatus M35
L. jensenii 62G
G. vaginalis AmMS 117
G. vaginalis 594
% inh
95% CI
8276–88%
8484–84%
4-16–23%
5-5–14%
28-1–61%
-9-16–4%
In the culture plate assay, L. crispatus strains 60 and SJ-3C completely prevented E. coli lawn formation over 6 replicate experiments. After correcting for protein and pH, the inhibitory activity of the SCS from L.
crispatus strain 60 persisted, whereas the other SCS lost activity.
CONCLUSIONS: SCS from bacterial strains differ in their capacity to inhibit E. coli growth and L. crispatus 60 exhibited the most potent activity independent of pH. Fractionation studies are in progress to identify the
specific SCS components that mediate this activity. These findings support the role of healthy microbiota in the defense against vaginal colonization with potentially pathogenic E. coli and suggest that this innate
activity could be harnessed to reduce neonatal sepsis and recurrent UTI.
Filename: 750442
Presenting Author: Caleb Seufert, MSPH
Department/Institution/Address: University of Vermont College of Medicine, Burlington, VT, 05401, United States
Phone: 240-401-7070
Fax:
Title: The Effects of Neuropeptide Substance P and NK1R Antagonist on Program Death Receptor-1 Expression in CD4+ T-cells
Caleb Seufert1, Serguei Spitsin2, Florin Tuluc2,3, Angela Winters2 and Steven D. Douglas2,3. 1University of Vermont College of Medicine, Burlington, VT; 2Children's Hospital of Philadelphia Research Institute,
Philadelphia, PA and 3Perelman School of Medicine, Philadelphia, PA.
BACKGROUND: Substance P (SP) is a tachykinin produced in neurons and immune cells and involved in nociception and inflammation. Neurokinin 1 receptor (NK1R) is the preferred receptor for SP and mediates
many biological responses. Increased SP levels are present in HIV-infected individuals and NK1R antagonist have shown anti-HIV effects. Aprepitant is a NK1R antagonist approved as an antiemetic. Major advances
in combination antiretroviral therapy (cART) have decreased HIV-related morbidity and mortality, however immune restoration remains incomplete. Negative co-signaling molecule programmed-death receptor 1
(PD-1) suppresses T-cell activation and contributes to poor immune restoration in HIV infection. PD-1 expression is upregulated in HIV infection and may contribute to accelerated pathogenesis of CD4+ T-cell
depletion and exhaustion. A recent Phase 1B trial of Aprepitant showed reduction of PD-1 expression by CD4+ T-cells in vivo (CROI 2014, abstract 338) which may direct future studies to focus on NK-1R blockade
as an adjunctive therapy.
OBJECTIVE: To determine in vitro effects of SP and Aprepitant on CD4+ T-cell expression of PD-1. Study of SP effects on the immune system will lead to a better understanding of the biological effects of using
aprepitant therapy among HIV-positive patients.
DESIGN/METHODS: PBMC from normal donors were treated with SP, Aprepitant (10µM each) or combination SP+Aprepitant. Flow cytometry characterized expression of PD-1 by using PE anti-human CD279
(PD-1) antibody.
RESULTS: CD3+/CD4+ cells averaged 36.19% PD-1 expression after 6 days of single SP treatment. CD3+/CD4+ cells had an average of 38.4% (p=0.03) PD-1 expression after 8 days of multiple SP treatments (day
0, 1, 5). Aprepitant treated and non-treated control cells demonstrated 3.28% and 9.79% PD-1 expression, respectively. SP + Aprepitant treated cells demonstrated an average 4.76% PD-1 expression.
CONCLUSIONS: Elevated PD-1 expression among SP treated T-cells as compared to the non-treated control was consistently demonstrated. Our in vitro experimental results are consistent with the in vivo results
demonstrated by the recent Phase 1B trial study. PD-1 is considered a possible HIV therapeutic target and may be a key biological target for immune reconstitution among HIV-positive patients.
Filename: 754329
Presenting Author: Jonathan M. Beus, MD, MS
Department/Institution/Address: Division of Infectious Diseases, The Children's Hospital of Philadelphia, 3535 Market Street, Philadelphia, PA, 19104, United States
Phone: 404-374-5710
Fax:
Title: Trends in Antimicrobial Susceptibility of E. Coli Causing Community Onset UTI in Children
Jonathan M. Beus1, Carter L. Cowden1, Kaede V. Sullivan2, Daniele Dona1 and Jeffrey S. Gerber1. 1Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA and 2Clinical Microbiology
Laboratory, Division of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Community-onset urinary tract infection (UTI) is a common indication for antibiotic use in children. Empiric antibiotic choice should be driven by clinical microbiologic data for E. coli, as it accounts for
most pediatric UTIs. Many antibiograms represent composite inpatient and outpatient data, without restriction to confirmed UTI. Empiric antibiotic choice may be optimized with susceptibility information from
lab-confirmed community-onset UTI.
OBJECTIVE: To define trends in resistance for E. coli from lab-confirmed community-onset UTIs.
DESIGN/METHODS: This was a retrospective, time-series study of urine cultures from ambulatory encounters by children (2 mo-11 yr), presenting to 29 community-based practices and one emergency department
(1/2005-9/2013). Trends in susceptibility were examined with longitudinal marginal logistic regression, clustered by patient, and standardized for age, race, and practice type. Only positive urine cultures for single
organisms >= 100K CFU (>= 50K CFU if catheterized) were included. Patients were required to have inflammation on urinalysis (leukocyte esterase) and were excluded for recent antibiotic use.
RESULTS: E. coli comprised 90% of positive cultures from 2910 unique patients (24.8% from the ED). E. coli susceptibilities were lowest to aminopenicillins (54-64%), TMP-SMX (79-87%), and cefazolin (84-98%).
Over time, cefazolin (p<0.001), nitrofurantoin (p<0.001), and TMP-SMX (p=0.03) exhibited decreasing susceptibility. Susceptibilities to ciprofloxacin and ceftriaxone were high and remained stable. All isolates tested
(n=1868) were susceptible to amikacin.
CONCLUSIONS: Analyzing urine culture data from ambulatory patients diagnosed with UTI informs empiric antibiotic therapy for children presenting with this frequent condition. For some commonly prescribed
antibiotics with relatively narrow antimicrobial spectrums, susceptibility is low and/or decreasing. Several agents remain available for UTI therapy, although they tend to be broader-spectrum agents.
Filename: 754732
Presenting Author: Annette Scheid, MD
Department/Institution/Address: Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Enders Rm 730, Boston, MA, 02115,
United States
Phone: 001-617-919-2906
Fax: 001-617-730-0254
Title: TLR-7/8 Agonists and Bacille Calmette Guerin (BCG) Activate Robust Cytokine Production in Preterm Cord Blood
Annette Scheid1,2, David J. Dowling1, Ilana Bergelson1, Matthew A. Pettengill1, Helen Christou3, Tobias R. Kollmann4 and Ofer Levy1. 1Department of Medicine, Division of Infectious Diseases, Boston Children's
Hospital and Harvard Medical School, Boston, MA; 2Division of Newborn Medicine, Floating Hospital for Children at Tufts Medical Center, Boston, MA; 3Department of Pediatric Newborn Medicine, Brigham and
Women's Hospital and Harvard Medical School, Boston, MA and 4Division of Infectious and Immunological Diseases, Department of Pediatrics, University of British Columbia, Vancouver, Canada.
BACKGROUND: Preterms, >10% of all newborns worldwide, have a heightened risk of infection. Immunization is key to protecting from infection, but immunity of preterm infants is impaired, limiting protective
responses to sub-unit vaccines such as hepatitis B virus (HBV) vaccine. Adjuvantation by using live attenuated self-adjuvanted vaccines such as BCG, activating multiple Toll-like receptors (TLRs), or by the addition
of TLR agonists (TLRAs) boosts Th1 (cell-mediated immunity), Th2 (antibody)-polarizing and Th17 polarizing cytokine responses that may enhance vaccine responses. Some clinical studies suggest BCG, the target
of renewed interest due to potential beneficial heterologous anti-infective effects, may enhance responses to other vaccines in vivo. Little is known whether such enhancing effects extend to the preterm.
Characterizing preterm Th-polarizing cytokine responses to adjuvants and vaccines may inform preterm immunization.
OBJECTIVE: To assess preterm production of TNF and IL1β which enhance Th1 and Th17 polarization respectively in response to stimulation with TLRAs, BCG, HBV and the combination of BCG and HBV.
DESIGN/METHODS: Preterm (31 5/7-34 6/7 week gestational age (GA)), and term (>37 week GA) cord blood as well as healthy adult peripheral blood was collected (N= 7-8/group), promptly diluted (≤4 hours)
diluted and added to a 96 well plate for 6 hour stimulation with TLRAs: Pam3CSK4, Poly I:C, MPLA and lipopolysaccharide, imidazoquinolines Gardiquimod, R848, CL075, or CpG-C or vaccines: HBV (Recombivax
HB®, Merck and Co, Inc), BCG (Danish Strain 1331, Statens Serum Institut) as well as HBV plus BCG. Cytokine concentrations in supernatants were analyzed by ELISA (N=7-8 /group).
RESULTS: Preterms demonstrated diminished LPS- and CL075-induced IL-1β production compared to terms. In contrast, R848 induced both TNF and IL-1β in the preterm to adult-like levels. With respect to
vaccines, in marked contrast to HBV alone, BCG, given alone or with HBV, significantly induced robust (adult-level) preterm production of TNF and IL-1β.
CONCLUSIONS: The imidazoquinoline R848 and BCG (alone or in combination with HBV) induce robust TNF and IL-1β production in preterm blood. Both TLR7/8As and BCG should be further studied as adjuvant
approaches to enhance preterm immunization. Funding: Bill & Melinda Gates Foundation and NIH grants RO1AI067353-01A1 and 3R01AI067353-05S1.
Filename: 753701
Presenting Author: Umesh Paudel, MBBS
Department/Institution/Address: Dept. of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, 100 Woods Rd, Valhalla, NY, 10595, United States
Phone: 9144938558
Fax: 9144931488
Title: Genetic Variation of Interleukin13 Gene Is Associated with Bronchopulmonary Dysplasia in Extremely Low Birth Weight Infants
Umesh Paudel1, Alex Feldman1, Usama Younis1, Lynnette H. Kim1 and Lance A. Parton1. 1Dept. of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY.
BACKGROUND: BPD is a major concern in the care of extremely low birth weight infants. Inflammatory pathway among others is a known contributor to BPD. Interleukin13, a crucial mediator of inflammation, has
been associated with abnormal fibrosis, and emphysematous changes in lung and single nucleotide polymorphism in IL13 gene are known to mediate these changes. Clinical studies have shown that rs1800925 (snp
at promoter region) and rs20541 (snp at exon 4) are closely linked to pulmonary fibrosis, chronic obstructive airway disease and airway remodeling in asthma. In this study, we seek to determine the association of
these snps with BPD in extremely low birth weight infants.
OBJECTIVE: To test the hypothesis that rs1800925 and rs20541 are associated with susceptibility to BPD in ELBW infants.
DESIGN/METHODS: This is an ongoing cohort study that enrolls infants weighing <1 kg at birth, without congenital or chromosomal anomalies. BPD is defined as need for O2 at 36 weeks post-menstrual age. DNA
was isolated from buccal mucosal swabs (N=124) and subjected to allelic discrimination using Taqman probes for IL13 rs1800925 and rs20541 during real-time PCR. X2 test and t-test were performed with P<0.05
denoting statistical significance.
RESULTS:
No BPD (n=44)
BPD (n=80)
p value
Gestational age (mean± SD)
26.2 ±1.9
25.1 ±1.6
0.001
Birth weight (mean± SD)
799 ±130
722 ±135
0.003
Male Gender
20 (45%)
40 (50%)
0.8
17 (38%)
20 (25%)
Black
9 (20%)
28 (35%)
Hispanic
18 (40%)
28 (35%)
Caucasian
Race
Other
0.1
1 (2%)
3 (4%)
24 (55%)
65 (81%)
0.01
NEC
2 (5%)
14 (18%)
0.12
IVH (≥ Grade 3)
4 (9%)
13 (16%)
0.3
ROP (≥ Grade 3)
1 (2%)
5 (6%)
0.3
CC
22 (52%)
44 (55%)
Ct
15 (36%)
26 (33%)
tt
5 (12%)
10 (13%)
AA
7 (17%)
29 (36%)
Ag
29 (71%)
40 (49%)
gg
5 (12%)
12 (15%)
Any g
34 (83%)
52 (64%)
PDA (med/surg rx)
Genotype
rs1800925
rs20541
0.9
0.06
0.03
Birth weights and gestational ages were smaller in the BPD group, and BPD group had a higher number of PDA. rs20541 was significantly less with BPD group.
CONCLUSIONS: In this pilot study, ELBW preterm infants with BPD were less likely to contain the minor allele for IL13 rs20541. We speculate that IL13 variant may confer protection from BPD by altering the
cytokine-receptor interaction leading to the less activity of IL13 and downregulation of proteolytic enzymes downstream involved in modulation of lung parenchyma
Filename: 756378
Presenting Author: Anna V. Hoplamazian
Department/Institution/Address: 3615 Civic Center Blvd, ARC building Rm415h, philadelphia, PA, V, United States
Phone: 01-215-590-1653
Fax: 01-267-426-5632
Title: Heme Oxygenase (HO)-1 Regulates Mitochondrial Function Leading To Iron Accumulation
Anna V. Hoplamazian1, Ping La1 and Phyllis A. Dennery12. 1Division of Neonatology, Children's Hospital of Philadelphia, philadelphia, PA and 2Department of Pediatrics, University of Pennsylvania School of Medicine,
Philadelphia, PA.
BACKGROUND: Disruption of HMOX1 in mice or human leads to anemia associated with very low serum iron levels, but with iron accumulation in the liver and kidneys. This can worsen susceptibility to oxidative
stress. Iron is transformed into its biologically available forms, iron-sulfur (Fe/S) cluster and heme, in the mitochondrion. Since heme is critical to mitochondrial function, in particular to electron transport chain function,
we speculate that HO-1 deficiency affects mitochondrial function, which in turn leads to abnormal iron processing.
OBJECTIVE: To determine how HO-1 insufficiency affect mitochondria status and thus imbalance iron homeostasis.
DESIGN/METHODS: The expression of heme oxygenase (HO)-1, the rate-limiting enzyme in heme degradation and delta-aminolevulinate synthase 1 (ALAS1), the first enzyme in heme synthesis, were inhibited using
lentivirus shRNA in mice embryonic fibroblasts NIH3T3- L1 cells, Human liver carcinoma cells HepG2 or cervical cancer cells Hela. Overexpression of ALAS1 was achieved by retroviruses infecting HMOX1-/- or
HMOX1+/+ MEFs. Protein and mRNA levels were measured by western blot and Taqman RT-PCR assays.
RESULTS: Infection with HO-1 shRNA lentiviruses elevated cellular heme levels in cultured HepG2, HeLa, and 3T3-L1 and inhibited gene expression of ALAS1, the rate-limiting enzyme in heme synthesis. These
results were replicated in HMOX1-/- MEFs compared to HMOX1+/+. Furthermore, HO-1 insufficiency in these cells increased mitochondria biomass, ETC complex I activity, and the expression of PGC-1a, a prominent
modulator of mitochondrial function. Additionally, gene expression of ferroportin (FPN1), the only known iron-export protein, was decreased by silencing HO-1. Although 3T3-L1 cells with ALAS1 knockdown share the
same phenotype as those with HO-1 knockdown, only the former showed decreased heme levels, implying that heme is not responsible for the changes in mitochondrial function. Exogenous expression of ALAS1 in
HMOX1-/- MEFs restored FPN1 gene expression and decreased the upregulation of PGC-1a, confirming that ALAS1 deficiency, whether by HO-1 or ALAS1 inhibition, affects mitochondrial function and iron efflux.
CONCLUSIONS: HO-1 deficiency affects mitochondrial function by inhibiting ALAS1 gene expression and heme synthesis, thereby contributing to iron accumulation.
Filename: 755434
Presenting Author: Gustavo Nino, MD, MSc
Department/Institution/Address: 111 Michigan Ave NW, Washington, DC, 20010, United States
Phone: 202-476-5000
Fax: 202-476-5000
Title: Premature Children Have Dysfunctional Airway Cytokine Responses To Rhinovirus and Respiratory Syncytial Virus
Gustavo Nino1, Krishna Pancham1, Shehlanoor Huseni1 and Geovanny Perez1. 1Pediatric Pulmonary and Sleep Medicine, Children's National Health System, Washington, DC.
BACKGROUND: It is unknown why children born very premature are highly susceptible to rhinovirus (RV) and respiratory syncytial virus (RSV) in early life.
OBJECTIVE: To investigate if there are dysfunctional airway antiviral (Th1) and pro-asthmatic (Th2) cytokine responses to RV and RSV in young children with history of prematurity.
DESIGN/METHODS: We measured Th1/Th2 nasal airway cytokines in a cohort of young children aged 0-3 years without detectable virus or with PCR-confirmed RV or RSV infection. Protein levels of IL-4, IL-13,
thymic stromal lymphopoietin (TSLP), IFNγ and IL-12 were determined with multiplex immunoassays. Demographic and clinical variables were obtained by electronic medical record (EMR) review.
RESULTS: The study comprised a total of 200 children born full term (n=108) or very premature (n=92). Overall, naturally aquired RV infection was associated with an airway Th2 cytokine bias. During RV infection
very premature children (<32 weeks gestation) had a greater elevation in airway Th2 cytokines (IL-4 and IL-13) relative to individuals born full-term. Very premature children with RSV infection did not have absolute
increase in Th2 cytokines relative to full-term children but their Th1(IFNγ)/Th2 (IL-4) ratios were overall reduced.
CONCLUSIONS: Our study is the first to demonstrate that young children with history of severe prematurity have defective Th1/Th2 airway cytokine responses. RV was associated more airway secretion of Th2
cytokines relative to RSV but very premature children had distinct airway cytokine responses to both viruses. Accordingly, our data provide novel insights about the potential reason why RV and RSV cause severe
respiratory disease in children with history of prematurity.
Filename: 750933
Presenting Author: Lawrence M. Rhein, MD
Department/Institution/Address: 41 Varick Hill Rd, Waban, MA, 02468, United States
Phone: 617 833 7334
Fax:
Title: Apnea Management in the Outpatient Setting: Is There a Role for Polysomnograms
Serena Haver1, Annelise Chaparro1, Caitlin E. Raimondi1, Stefanie Griglak1 and Lawrence M. Rhein1,2. 1Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA and 2Division of Newborn Medicine,
Boston Children's Hospital, Boston, MA.
BACKGROUND: Subsets of preterm and full term infants have persistent apneic events in the neonatal period, which often prolong hospitalization. One treatment approach includes use of home monitors (HMs) to
allow earlier discharge. Standardized guidelines to determine timing of safe discontinuation of HMs do not exist. Some centers utilize polysomnograms (PSGs) to determine safety of discontinuing HM use. Evaluation
of this practive has not been previously described.
OBJECTIVE: The goal of this project is to describe results of PSGs used in discontinuing HM use.
DESIGN/METHODS: We identified all infants that visited Boston Children's Hospital Pulmonary Clinic (age < 6 months at time of visit) from May 2004-14 with diagnosis of apnea who underwent PSG to wean off HM
use. We extracted data from PSG records including physician interpretation and documented changes in management based on PSG findings.
RESULTS: A total of 101 infants underwent PSGs, within an age range of 40 3/7-49 6/7 weeks corrected gestational age (CGA) at time of PSG.
Of the 16% that were officially interpreted as abnormal, all but one had normal physiologic parameters for oxygenation and ventilation; most had excessive percentage of periodic breathing although only 1/3 required
further follow-up.
All subsequent diagnostic evaluations were negative for clinically relevant findings.
CONCLUSIONS: Consistent with older studies, all infants in our cohort had normal physiologic parameters after 44 weeks CGA. Routine use of PSGs to determine safe discontinuation of HMs is likely unnecessary.
Filename: 754371
Presenting Author: Suhita Gayen nee Betal
Department/Institution/Address: Pediatrics/Neonatology, Nemours at Jefferson, 833 Chestnut Street, Suite 1210, Philadelphia, PA, 19107, United States
Phone: 4845571160
Fax:
Title: High Dose of Vitamin D Decreases Lung Alveolarization in a Rat Model of LPS and Hyperoxia-Induced Lung Injury
Deepthi Alapati1, Suhita Gayen nee Betal2, Mendira Chawla2, Avani Vachhani3, Dalal Taha4, Ursula Nawab4, Kristin Mckenna4, Swati Murthy2, Janet Larson2 and Zubair H. Aghai2. 1Pediatrics/Neonatology, Nemours AI
duPont Hospital for Children, Wilmington, PA; 2Pediatrics/Neonatology, Nemours at Jefferson, Philadelphia, PA; 3Jefferson Medical College, Philadelphia, PA and 4Pediatrics/Neonatology, Childrens Hospital of
Philadelphia, Philadelphia, PA.
BACKGROUND: Vitamin D (VitD) has been suggested to play an important role in fetal lung maturation, but the underlying mechanisms are poorly understood. Vitamin D receptor (VDR) induces gene expression and
regulates diverse biological functions. We have previously demonstrated that high dose of VitD increases the expression of VDR in neonatal rat lung exposed to intrauterine LPS and postnatal hyperoxia in a dose
dependent manner
OBJECTIVE: To study the effect of high dose of VitD on lung alveolarization in a neonatal rat model of chorioamnionitis and hyperoxia
DESIGN/METHODS: Timed pregnant Sprague-Dawley rats were anesthetized on gestational day 20 and DMEM or 1µg of LPS was injected in to the amniotic sac. Postnatal hyperoxia(O2) was provided by exposure
to 85% oxygen for 14 days in a sealed tank. VitD or Normal Saline(NS) was injected intraperitoneally for 14 days. Pups were divided into 8 groups; Control group 1(DMEM+RA), DMEM+VitD (Gr2, 3 for 250ng and
500ng VitD per kg), LPS only (Gr 4), LPS+O2+NS (Gr 5), LPS+O2 + VitD (Gr 6, 7, 8 for 250ng, 500ng and 1µg VitD per kg). Alveolarization was quantified by measuring Mean Linear Intercept (MLI) and proliferation
was assessed by staining for PCNA and quantifying the number of PCNA positive cells per high power field (HPF). Total protein was isolated from lung tissues followed by Western Blot for p21 antibody
RESULTS: 14 days of postnatal hyperoxia coupled with intrauterine LPS exposure, significantly increased MLI by 58%(p<0.01). VitD treatment in Gr 2 &3 resulted in 16% and 60%(p<0.01) increase in MLI
respectively. Additionally, treatment with high dose of VitD (gr 6,7 & 8) worsened hyperoxia-induced alveolar impairment in a dose dependent manner- 25%, 103% & 147%(p<0.001) respectively compared to control
group. Increased MLI induced by VitD was associated with 40% decrease in PCNA positive cells per HPF in hyperoxia exposed rat pups treated with VitD 250ng/kg & 500ng/kg(p<0.01) and by 44% with VitD
1ug/kg(P<0.01). p21 was increased by 33% in LPS+O2 group. VitD exposure showed 39%, 135% (p<0.01) and 132% (p<0.01) increase of p21 with gr 6,7 & 8respectively
CONCLUSIONS: High dose of VitD decreased alveolarization by increasing expression of p21 and decreasing proliferation in a dose dependent manner in neonatal rat pups exposed to chorioamnionitis and post natal
hyperoxia
Filename: 751970
Presenting Author: Vikramaditya Dumpa, MD
Department/Institution/Address: Division of Neonatology, State University of New York at Buffalo, 219 Bryant St, Buffalo, New York, 14222, United States
Phone: +17168787673
Fax:
Title: Caffeine Modulates Hyperoxia Induced Angiogenesis in Newborn Mice
Vikramaditya Dumpa1, Huamei Wang1, Lori Nielsen1 and Vasanth H.S. Kumar1. 1Division of Neonatology, Department of Pediatrics, State University of New York at Buffalo, Buffalo, NY.
BACKGROUND: Caffeine therapy for apnea of prematurity reduces the incidence of bronchopulmonary dysplasia (BPD) in very low birth weight (VLBW) infants. However, the molecular mechanisms underlying the
reduction in BPD with caffeine are uncertain, they could be multifactorial. As vascular development promotes alveologenesis, we hypothesized that caffeine promotes angiogenesis in the lung, attenuating BPD.
OBJECTIVE: To study the effects of caffeine on the expression of hypoxia inducible factors (HIF-1) and angiogenic genes in the lung of newborn mice with hyperoxia induced lung injury.
DESIGN/METHODS: Newborn mice litters were randomized within 12h of birth to 21%O2 or 95%O2 for 4 days (P1-P4). Mice litters were randomized to receive caffeine (20mg/kg/day X 4 doses - CAF) or normal
saline (NS) by daily intraperitoneal injection (P1-4) & sacrificed on P5. Whole lung mRNA was isolated (N=7 in each group) and the expression of genes representing the HIF pathway and angiogenesis (HIF1α,
HIF2α, HIF3α HIF1β, PHD2, Ang1 & VegfR1) in whole lung was assessed by qRT-PCR. Data were analyzed on PCR array online web portal (SA Biosciences, MD); Data were compared to the 21%O2+NS group.
RESULTS: Caffeine upregulates HIF1α & HIF2α along with angiogenic genes Ang1 and VegfR1 in the room air (RA) group. 95%O2 upregulates HIF 1α/2α, however this is not accompanied by overexpression of
angiogenic genes. Addition of caffeine to 95%O2 group downregulates the expression of HIF2α and Ang1 mRNA expression.
Table1. Fold change in gene expression by qRT-PCR of selected
genes in newborn mice exposed to 21%O2 or 95%O2. Genes with
FC≥2.0 & p<0.01 are considered significant; *P<0.01 versus
21%O2+NS (Control Group); †P < 0.01 versus 95%O2+NS
Genes 21%O2 + Caffeine 95%O2 + Saline 95%O2 + Caffeine
HIF1α 2.03 (1.16-2.90)*
2.18 (1.54-2.82)* 2.12 (1.17-3.07)
HIF2α 2.61 (1.65-2.37)*
2.61 (1.63-3.59)* 1.38 (0.87-1.89)†
HIF3α 2.56 (1.33-3.79)
1.65 (1.01-2.59)
1.38 (0.83-1.93)
HIF1β 1.76 (1.34-2.18)
1.68 (1.27-2.09)
1.42 (1.13-1.71)
PHD2
1.72 (1.22-2.36)
1.78 (0.53 (3.03) 0.75 (0.63-1.27)
Ang1
2.72 (1.94-3.50)*
1.31 (1.01-1.61)
0.78 (0.55-1.01)†
VegfR1 2.09 (1.59-2.59)*
1.84 (1.58-2.10)
1.37 (0.89-1.85)
CONCLUSIONS: Caffeine may promote angiogenic gene expression at lower O2 concentrations. However, its effects on the lung at high O2 concentrations needs to be explored further.
Filename: 752938
Presenting Author: Amanda Bader, B.A.
Department/Institution/Address: 159 East 30th Street, Apt 14B, New York, NY, 10016, United States
Phone: 5168519391
Fax:
Is Presenting Author a Trainee? Yes, Other - Post-Bacc; applying to Med School
Title: The Impact of State Laws Regarding Contraception Access and Use by Teen-Age Girls in the United States
Amanda Bader1, Sujit Vettam2 and Andrew Adesman1. 1Developmental & Behavioral Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY and 2Vettam Data Solutions, Baltimore, MD.
BACKGROUND: Although teen pregnancy statistics continue to decline, a total of 305,388 babies were born to women aged 15–19 years in 2012 (CDC). Teen pregnancy is a significant contributor to high school
drop-out rates among girls; only about 50% of teen mothers receive a high school diploma by age 22. Despite these troubling statistics, teenage girls continue to have difficulty accessing prescription birth control.
Many states allow pharmacies to refuse to fill birth-control prescriptions. Only 7 states in the U.S. have laws guaranteeing minors access to birth control prescriptions and only 22 states allow minors to consent to
contraceptive treatment.
OBJECTIVE: To assess the impact of state laws regarding contraception access and contraception use by teenage girls in the United States.
DESIGN/METHODS: The Youth Risk Behavior Surveillance System (YRBSS) is a biannual national survey conducted by the CDC that provides data representative of 9th through 12th grade students in public and
private schools in the U.S. Responses to the 2013 YRBSS National questionnaire were used to obtain data on birth control (BC) use among high school girls, including birth control pills, rings and shots. Analyses were
done comparing BC use in states with laws versus states with no laws for guaranteed access to prescriptions and in states with laws versus states without laws allowing minors to independently consent to
contraception. Logistic regression models and chi-square tests were used to assess these relationships via odds ratios and significance values. Analyses were done using procedures suited for survey data in SAS
9.2.
RESULTS: 1198 high school girls reported using BC. A lower percentage of girls reported BC use in states with guaranteed access than in states without guaranteed access (49.5 ± 6.6% vs. 65.4 ± 2.4%; Rao-Scott
χ2, p=0.0065); however, after adjusting for age, grade, and race/ethnicity, there was no significant difference (aOR (95% CI) =.780 [0.451 – 1.349]. No difference was likewise noted regarding BC use in the 22 states
with laws explicitly allowing minors to consent to contraceptives (61.4 ± 3.0%) vs. 28 states without explicit consent laws (62.9 ± 4.9%) [Rao-Scott χ2, p=0.80].
CONCLUSIONS: Although states vary considerably with respect to legislative entitlement of teenagers to contraception, there were, surprisingly, no significant differences noted in birth control use in a nationally
representative sample of high school girls in the United States
Filename: 751762
Presenting Author: Maria F. Ramirez-Tovar, MD
Department/Institution/Address: Pediatrics, St. Barnabas Hospital, 4422 3rd Ave, Bronx, NY, 10457, United States
Phone: 718-960-6635
Fax: 718-960-9418
Title: Prevalence of Male Sexual Victimization and Association with Adverse Health Outcomes
Maria F. Ramirez-Tovar1, Janine Clark-Adjo1,2, Paulo Pina1,2 and David Rubin1,2. 1Pediatrics, St. Barnabas Hospital, Bronx, NY and 2Pediatrics, Albert Einstein College of Medicine, Bronx, NY.
BACKGROUND: The 2011 National Intimate Partner and Sexual Violence Survey reports that almost two million men have been raped during their lifetime, and interestingly, men and women had a similar prevalence
of non consensual sex in the 12 months prior to being surveyed. In 2013 the lifetime experience of 17 year-old boys with sexual abuse or assault was 5.1%, and 1.9% at the hands of adult perpetrators. Sexual
victimization of female adolescents is associated with depression, suicidal behavior, alcohol consumption; but no sufficient data exists in males.
OBJECTIVE: To determine the prevalence of sexual victimization and its association with several adverse health outcomes in adolescent males.
DESIGN/METHODS: Secondary analysis of public use data from Waves III (2001-2002), and IV (2007-2008) of the National Longitudinal Study of Adolescent Health (Add Health) was analyzed. Self-reported data
was obtained from Wave III and Sexually Transmitted Infection's (STI's) Biomarkers were obtained from wave IV. Bivariate associations between victimization and other variables were explored, as well as multivariate
linear and logistic regression models were done.
RESULTS: Sample was composed of 2253 males participating in Wave III, age ranging from 12 to 21 years at enrollment. 3.9% reported sexual abuse by an adult or caregiver before starting the 6th grade. Victimized
adolescent males were 1.9 times more likely to experience depression (CI 1.03-3.78). Propensity to risky sexual behaviors trended to significance, specifically having multiple partners in a year; but condom use, early
age at first coitus, and prevalence of STI's showed no significance. Other adverse behaviors like binge drinking and drug use were not significant either. Results were adjusted by race.
CONCLUSIONS: These results support the importance of screening male adolescents for sexual abuse and victimization from an early age. Establishing appropriate interventions for secondary and tertiary prevention
should be an inherent goal in practice. Furthermore, effectively changing the perception of males as not plausible sexual victims requires commitment not only from health care workers, but from law enforcement
agencies as well.
Given the myths surrounding male sexual victimization under-reporting could be a significant limitation, but further studies should be directed towards determining type of victimization, usual perpetrators, and effective
actions to decrease the raising prevalence of abuse.
Filename: 751425
Presenting Author: Charles Thompson, MD
Department/Institution/Address: Pfizer, 82 Lords Hill Road, Stonington, CT, 06378, United States
Phone: 8604607195
Fax:
Title: Assent in Pediatric Clinical Trials: An International Children's Advisory Network (iCAN) Survey
Charles Thompson1, Sharon Smith2, Philip Sjostedt3 and Donald Lombardi4. 1Pfizer, New York, NY; 2Connecticut Children's Medical Center, Hartford, CT; 3The Medicine Group, New Hope, PA and 4Institute for
Pediatric Innovation, Cambridge, MA.
BACKGROUND: The FDA, EMA, and other regulatory agencies require assent be obtained from pediatric subjects participating in clinical trials, in addition to parental informed consent. Despite these requirements,
there is limited guidance regarding the appropriate age range or effective methods for obtaining assent. There is a need to engage stakeholders across the pediatric community to develop consensus on assent
practices.
OBJECTIVE: To understand the perspective of children, parents, and caregivers on assent procedures in pediatric clinical trials.
DESIGN/METHODS: A 21-question internet survey on pediatric assent was distributed to members of KIDS (Kids and Families Impacting Disease through Science) and ICAN (International Children's Advisory
Network).
RESULTS: 47 participants (Parent, 47%, n=22; Child, 45%, n=21; Caregiver, 8%, n=4) completed the survey. Most respondents were female (n=74%, n=35/47), living in the USA (79%, n=37/47), with no direct assent
experience (64%, n=30/47). Most respondents felt children 7-10yrs were old enough to provide assent (44%, n=20/45), followed by children 11-14yrs (31%, n=14/45). Cultural (69%, n=31/45), gender (71%, n=32/45),
and disease (71%, n=32/45) issues may also influence the assent process. The availability of standardized assent tools would be beneficial in achieving pediatric assent (89%, n=40/45), specifically electronic tools
(76%, n=34/45) previously validated by children (91%, n=41/45).
CONCLUSIONS: This survey highlights the need for age appropriate, standardized electronic tools and visual aids that have been evaluated by children and parents to assist in the informed consent/assent process.
This will ensure that the child or young person fully understands the nature and consequences of participation in the trial.
Filename: 754760
Presenting Author: Amanda R. Kreider, BS/BA
Department/Institution/Address: PolicyLab, The Children's Hospital of Philadelphia, 3535 Market St., Room 1537, Philadelphia, PA, 19104, United States
Phone: 267-426-9832
Fax:
Title: Risk of Incident Diabetes Following Initiation of Second-Generation Antipsychotics among Medicaid-Enrolled Youth
David M. Rubin1,2,3, Amanda R. Kreider1, Meredith Matone1, Yuan-Shung Huang3,4, Chris Feudtner1,2,3, Michelle E. Ross5 and Russell Localio5. 1PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA;
2
Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 3Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; 4Healthcare
Analytics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA and 5Department of Biostatistics and Epidemiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
BACKGROUND: By 2008, 1 in 4 Medicaid-enrolled children who were prescribed psychotropic medication received an antipsychotic, either singly or in a medication combination. Although metabolic side effects have
been linked to antipsychotic use in youth, estimating risk for incident type 2 diabetes, a rarer outcome, has been challenging.
OBJECTIVE: To determine whether antipsychotic initiation was associated with increased risk of incident type 2 diabetes. Secondary analyses examined the risk associated with multiple-drug regimens, including
stimulants and antidepressants, as well as of individual antipsychotics.
DESIGN/METHODS: Retrospective national longitudinal cohort study of US Medicaid-enrolled youth aged 10-18 years between January 2003 and December 2007. Youths initiating antipsychotics (initiators) and
unexposed youths (non-initiators) were identified in each month, and propensity weights were developed to balance observed demographic and clinical characteristics between exposure groups. Discrete-time failure
models were fit using weighted logistic regression to estimate the risk of incident diabetes for initiators and non-initiators of antipsychotics and within subgroups of interest.
RESULTS: Among 107,551 initiators and 1,221,434 non-initiators of antipsychotics, the risk of incident diabetes was increased among initiators (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.35 to 1.69;
P<0.001). Risk was higher among antipsychotic initiators concomitantly using antidepressants (OR, 1.94; 95% CI, 1.54 to 2.44; P<0.001), although similar among initiators using stimulants (OR, 1.47; 95% CI, 1.19 to
1.81; P<0.001). As compared to a reference group of risperidone initiators, risk was higher among those initiating ziprasidone (OR, 1.61; 95% CI, 0.99 to 2.64; P=0.06) and aripiprazole (OR, 1.58; 95% CI, 1.21 to 2.07;
P=0.001), but not quetiapine or olanzapine.
CONCLUSIONS: Risk of incident type 2 diabetes was increased among youths initiating antipsychotics and was highest in those concomitantly using antidepressants. Compared to risperidone, newer antipsychotics
were not associated with decreased risk.
Filename: 752931
Presenting Author: Tammy Pham
Department/Institution/Address: P.O. Box 203616, New Haven, CT, 06520, United States
Phone: 16193218776
Fax:
Title: Gender Differences in Risk of Weapon-Carrying By Adolescents Who Are Victims of Bullying
Tammy Pham1, Majnu John2, Lana Schapiro1 and Andrew Adesman1. 1Developmental & Behavioral Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY and 2Center for Psychiatric Neuroscience,
Feinstein Institute of Medical Research, NSLIJ, Manhasset, NY.
BACKGROUND: The prevalence of school bullying has serious implications for the safety of both victims of bullying (VoBs) and non-victims. Many attackers of targeted school violence were VoBs and had access to
weapons prior to the attack, suggesting that weapon-carrying (WC) at school may be a precursor to future violent behavior. Although analysis of the 2011 Youth Risk Behavior Survey (YRBS) data noted marked aORs
for WC among VoBs, gender differences were not examined and yet may be critical for targeted prevention efforts.
OBJECTIVE: To study gender differences in prevalence of VoBs, association with WC, and influence of additional risk factors (RFs) on WC by VoBs.
DESIGN/METHODS: Data from the 2013 national YRBS were analyzed for grades 9-12 (N=13,583, response rate=68%). Victim groups (VGs) were determined by response to, "During the past 12 months, have you
ever been bullied on school property?" and additional RFs, 1) skipped school because felt unsafe, 2) has been in a physical fight at school, and 3) has been threatened/injured with a weapon. WC was defined by
non-zero response to, "During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club on school property?" VGs were compared to non-victims with respect to WC, yielding adjusted
odds ratios (aORs). Analyses were done using procedures suited for survey data in SAS 9.2.
RESULTS: Compared to males, more females reported being a VoB (23.7% vs. 15.6%, p < .001). WC was more prevalent among males, compared to females (7.6% vs. 3.0%, p < .001). Percent of students reporting
WC in each VG and aORs compared to non-victims are shown in Table 1.
CONCLUSIONS: Although WC was more prevalent among males, aORs of female VGs against non-victims were much higher than male aORs, suggesting greater influence of bullying on WC for girls. VoBs
victimized in multiple ways were most likely to report WC. Anti-bullying interventions should recognize that protecting female VoBs may lead to significant decreases in WC.
Filename: 752930
Presenting Author: Tammy Pham
Department/Institution/Address: P.O. Box 203616, New Haven, CT, 06520, United States
Phone: 16193218776
Fax:
Title: Relative Risks of Depression and Suicidal Tendency Among Victims of School- and Electronic-Bullying With Co-Risk Factors
Tammy Pham1, Sujit Vettam2, Majnu John3 and Andrew Adesman1. 1Developmental & Behavioral Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY; 2Vettam Data Solutions, Baltimore, MD and
3
Center for Psychiatric Neuroscience, Feinstein Institute of Medical Research, NSLIJ, Manhasset, NY.
BACKGROUND: Electronic bullying has recently become recognized as a new and potent form of bullying. While school bullying typically ends when the victim of bullying (VoB) goes home, cyberbullying can continue
into the home after school hours. To date, there has been no national analysis of risk of depression (DP) and suicidal tendency (ST) among those who are VoBs at school only (SVs), VoBs by electronics only (EVs),
and VoBs both at school and by electronics (SVEVs) that has considered effects of co-risk factors (RFs).
OBJECTIVE: 1) To quantify the risk for DP and ST among SVs, EVs, and SVEVs against non-victims (NVs), and 2) To determine to what extent co-RFs increase risk of DP and ST among VoBs.
DESIGN/METHODS: Data from the 2013 national YRBS were analyzed for grades 9-12 (N=13,583, response rate=68%). Mutually exclusive groups (NV, SV, EV, SVEV) were determined by response to, "During the
past 12 months, have you ever been bullied on school property?" and "During the past 12 months, have you ever been electronically bullied?" Co-RFs included 1) involvement in violence, 2) drug/alcohol abuse, 3)
experience of relationship abuse, and 4) unhealthy dieting. DP was defined by feeling sad or hopeless every day for ≥ 2 weeks in a row, and ST was defined by seriously considering suicide, making a suicide plan, or
actually attempting suicide. VoB groups were compared to NVs with respect to DP and ST, yielding adjusted odds ratios (aORs). Analyses were done using procedures suited for survey data in SAS 9.2.
RESULTS: For all cases in Table 1, aORs of SVs did not differ from EVs. Except for "VoB + Relationship Abuse", aORs of SVEV were significantly greater than those of SV or EV.
CONCLUSIONS: SVEVs were more likely to have DP or STs compared to NVs, SVs, or EVs, showing that multiple forms of bullying can compound their negative effects. The shown aORs of VoBs with co-RFs should
help focus strategic interventions to reduce depression and teen suicide, the 3rd leading cause of death in young people.
Filename: 752669
Presenting Author: Abigail G. Kerson, BS
Department/Institution/Address: 420 E70th street, 12G, New York, NY, 10021, United States
Phone: 9178286895
Fax:
Title: Delirium in Critically Ill Children
Abigail G. Kerson1 and Chani Traube1. 1Weill Cornell Medical College, New York.
BACKGROUND: Delirium is acute neurologic dysfunction, associated with severe illness or its treatment. It has long been recognized in the adult intensive care unit population where it is associated with increased
mortality and length of hospital stay. Preliminary studies suggest substantially increased morbidity in critically ill children, although data has been limited by the lack of prospective universal screening in the pediatric
ICU (PICU). With the recent advent of pediatric delirium screening tools, we can investigate the extent of this problem.
OBJECTIVE: To determine the incidence of delirium in critically ill children.
DESIGN/METHODS: This is a prospective study of children admitted to the New York Hospital Weill-Cornell Medical Center PICU in the summer of 2014. Daily data was collected from the electronic medical record of
consecutive PICU admissions over the course of 8 weeks. Every child was routinely screened for delirium twice daily using the Cornell Assessment of Pediatric Delirium (CAPD), a rapid observational screening tool
scored by the bedside nurse. Children who screened positive were diagnosed with delirium. Children with developmental delay and a positive delirium screen required an assessment by a pediatric intensivist or
pediatric psychiatrist to confirm the diagnosis. A child was considered delirious until they had two sequential negative CAPD scores (24 hours delirium-free).
RESULTS: One hundred and forty four subjects were included in the data collection, which comprised 818 patient days. Of the 144 subjects, 28 were excluded due to absence of documentation of delirium screening.
Incidence of delirium in the remaining 116 subjects was 28.4% (33 subjects were ever delirious during their PICU stay). In the subjects that were ever delirious, the average time in the PICU until the development of
delirium was 3.7 days with a standard error of .55 days, a mode of 2 days, and a range from 1 to 18 days. Thirty of the 116 subjects were developmentally delayed, and 86 were not. The incidence of delirium in
developmentally delayed children was 53.3%, as compared to 19.8% in typically developed children (p<.003)
CONCLUSIONS: This prospective longitudinal study shows a cross-section of delirium in a single PICU over a 2 month period. The data show that delirium may be prevalent in critically ill children, and
developmentally delayed children are at higher risk. Further investigation is necessary to determine the scope of this problem, identify its associated risk factors, and target possible avenues for therapeutic
intervention.
Filename: 750761
Presenting Author: Melissa L. Langhan, MD, MHS
Department/Institution/Address: Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York St, Suite 1F, New Haven, CT, 06511, United States
Phone: 203-737-7433
Fax:
Title: Respiratory Depression Detected by Capnography: Are Children Being Safely Monitored While Recovering from Anesthesia?
Melissa L. Langhan1 and Lance Lichtor2. 1Department of Pediatric, Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT and 2Department on Anesthesiology, Division of Pediatric
Anesthesiology, Yale University School of Medicine, New Haven, CT.
BACKGROUND: The American Society of Anesthesiology recommends monitoring children in the post-anesthesia care unit (PACU) with pulse oximetry. However, pulse oximetry does not reliably recognize
respiratory depression. Capnography is a superior method to continuously monitor ventilation that detects hypoventilation and apnea within one breath. Although children are routinely monitored with capnography
during anesthesia, it is not routinely continued in the PACU where they remain at risk for respiratory depression.
OBJECTIVE: We hypothesize that children recovering from anesthesia suffer from respiratory depression that will be detected frequently by capnography.
DESIGN/METHODS: Otherwise healthy children age 1-21 years undergoing general anesthesia for elective surgery were enrolled immediately upon entering the PACU. A nasal-oral cannula was placed on the child
and attached to a portable capnography monitor. Nurses were blinded to the monitor. Children received standard monitoring with pulse oximetry. Rates of respiratory depression, hypoxia, and interventions for
respiratory events were recorded by research assistants not involved in patient care.
RESULTS: Two hundred children were enrolled; 52% were male, 55% were white, 95% were ASA classification 1 or 2, and the average age was 9 years. Upon entry to the PACU, 86% of subjects received
supplemental oxygen and 24% had an oropharyngeal airway. Capnography detected hypopneic hypoventilation (ETCO2<30mmHg) in 31%, bradypnea (ETCO2>50mmHg) in 9%, and apnea (ETCO2=0mmHg) in 28%
of subjects. Mild oxygen desaturations (SaO2<93% on room air or <95% on supplemental O2) occurred in 18% of patients, moderate desaturations (SaO2<85% on room air or <90% on supplemental O2) in 5%, and
severe desaturations (SaO2<80% on room air or <85% on supplemental O2) in 2%. Interventions for respiratory events only occurred in 4% of subjects.
CONCLUSIONS: Respiratory depression is commonly detected with capnography among children in the PACU, however interventions occurred infrequently, thus leading to oxygen desaturations. The addition of
capnography to standard monitoring practices may improve patient safety by reducing the frequency of hypoxia due to more frequent and earlier interventions by staff. We plan to educate PACU staff on the use of
capnography and determine if children have fewer adverse events when nurses use capnography in addition to pulse oximetry in the PACU as compared to when nurses use pulse oximetry alone.
Filename: 754062
Presenting Author: Kavita Morparia
Department/Institution/Address: 111 Michigan Ave NW, Washington, DC, DC, United States
Phone: 1-732-986-1191
Fax:
Title: Pediatric Residents' Competency and Comfort for Decisions Regarding Fluid Administration in Sick Children
Kavita Morparia1, Julie Berg2 and Sonali Basu1. 1Critical Care Medicine, Children's National Medical Center, Washington, DC and 2Emergency Medicine, Children's National Medical Center, Washington, DC.
BACKGROUND: Pediatric residents are the front-line providers in making decisions regarding fluid administration for sick children, yet little is known regarding their ability and confidence in making these judgments.
OBJECTIVE: We hypothesized that there would be a wide variation among residents in competency and comfort level in decisions regarding fluid administration and sought to highlight areas of weakness.
DESIGN/METHODS: We developed a questionnaire with four commonly encountered clinical scenarios and sent it to all 123 housestaff in a university-based pediatric residency training program in the US. Residents
chose course of action, then rated the factors used for decision-making and confidence level on a Likert scale. Descriptive statistics were used for data analysis.
RESULTS: We conducted a preliminary analysis of the first 28 responses received. For a child with warm septic shock not responding to 60 ml/kg fluid in one hour, 54% would give additional fluid and 39% would start
a vasoactive. 70% were at least reasonably confident with their decision, and while most relied on clinical signs of shock, there was no request for mixed venous saturations or lactate as decision points. For a child
intubated for severe respiratory illness in shock, only 14% would give additional fluid, with 71% citing a mild increase in CVP from 8 to 10 mm Hg as very important, despite this change occurring with the initiation of
positive pressure ventilation with high airway pressures. In contrast, 60% considered a low mixed venous saturation as only somewhat contributory, and 71% were only mildly confident with their choice. For an
asthmatic with severe tachycardia, diastolic hypotension and chest pain, 54% would give additional fluid and 64% were at least reasonably confident with their decision. For a girl with anaphylaxis showing no signs of
shock, 64% would either give fluid or increase vasoactives, with 82% citing a low CVP as very important in decision-making. Overall, only 15% were very confident with their decisions regarding fluid management.
CONCLUSIONS: There is a wide variability among pediatric residents' practices for fluid resuscitation in shock, with heavy reliance on central venous pressure and inadequate consideration of mixed venous
saturations and lactate in decision-making. Confidence level in decision-making ability is low, even in commonly encountered situations. A structured education program addressing some of these issues would be of
benefit.
Filename: 751426
Presenting Author: Lynn E. Zeits
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Effect of Hypoxia on Long-Term EGFR Activation Following Src Kinase Inhibition in the Cerebral Cortex of Newborn Piglet
Lynn E. Zeits1, Shadi Malaeb1, Juan Ballesteros1 and Maria Delivoria-Papadopoulos1. 1Dept. of Pediatrics, Drexel University and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Protein tyrosine kinases (PTKs) control critical processes such as transcription and cell death. Previously we showed hypoxia results in increased tyrosine phosphorylation of neuronal proteins
including the antiapoptotic proteins Bcl-2 and Bcl-xl. We have also shown hypoxia results in increased EGFR kinase activity, a membrane protein tyrosine kinase, and increased Src kinase activity, a non-membrane
protein tyrosine kinase, in the brain of hypoxic piglets.
OBJECTIVE: The present study tests the hypothesis that administration of an EGFR kinase inhibitor, PD168393, or a Src kinase inhibitor, PP2, before hypoxia results in longitudinal inhibition of EGFR kinase
activation.
DESIGN/METHODS: Piglets were assigned to 8 groups: normoxia (Nx, n=5), acute Hx (Hx, n=2), Hx followed by 1 day (Hx-1D, n=2) and 14 days recovery (Hx-14D, n=2) in Fi O2 0.21, Hx pretreated with PP2, 1
mg/kg i.v., 30 min prior to Hx followed by 1 day (Hx+PP2-1D, n=3) and 14 day recovery (Hx+PP2-14D, n=1) in FiO2 0.21, and HX pretreated with PD 168393, 1 mg/kg i.v., 30 min prior to Hx followed by 1 day
(Hx+EGFRi-1D, n=1) and 14 day (Hx+EGFRi-14D, n=1) in FiO2 0.21. Membranes were prepared from cerebral cortices, EGFR kinase was immunoprecipitared using an EGFR-specific antibody. EGFR kinase activity
was determined radioactively by measuring 33P incorporation into a tyrosine kinase-specific substrate.
RESULTS: There was an increase in EGFR kinase activity (pmoles/mg protein/hr) between Nx (738.5 ± 148.0) and acute Hx (1454.9 ± 6.4). During recovery, EGFR kinase activity was 1068.4 ± 226.9 in Hx-1D and
1923.9 ± 410.7 in Hx-14D (p<0.05 vs Nx). Following administered PD18393 the EGFR kinase activity was 165.8 in Hx+ EGFRi -1D and 172.3 in Hx+ EGFRi-14D. Following administered PP2 the EGFR kinase activity
was 1224.7 ± 280.8 in Hx+PP2-1D and 2247.8 in Hx+PP2-14D.
CONCLUSIONS: Following hypoxia, EGFR kinase activity persists 14 days in the Hx group. EGFR kinase inhibition leads to decreased levels of EGFR activity at 1 and 14 days following hypoxia. The hypoxia-induced
increased EGFR kinase activity persists despite Src kinase inhibition on day 1 and day 14. We speculate that EGFR kinase activation plays a significant role in the initial mechanisms of brain injury. As such, EGFR
kinase activation may further lead to long term propogation of hypoxic cerebral injury in the newborn piglet brain.
Filename: 753852
Presenting Author: Janet Lioy, MD
Department/Institution/Address: Neonatology, The Children's Hospital of Philadelphia, 34th Street & Civic Center Blvd, Philadelphia, Pa, 19104, United States
Phone: 215-430-3268
Fax:
Title: Successful Elements for Creating a Neonatal Airway Emergency Response Team At a Major Referral Children's Hospital
Janet Lioy1, Hitesh Deshmukh1 and Leane Soorikian1. 1Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Unanticipated life-threatening neonatal airway emergencies can occur commonly in neonatal-infant intensive care units, (N/IICU) caring for infants with airway anomalies . Often, situations arise
without warning and require immediate response rates by highly qualified pediatric otolaryngology, (ENT), or anesthesia personnel. Systematic process are lacking in these environments.
OBJECTIVE: To evaluate key elements during an airway emergency that improve or deficiencies that impede the likelihood of a successful outcome, such as delays in notification, critical team response times,
communication and equipment usage and outcomes during airway emergencies.
DESIGN/METHODS: We implemented a comprehensive neonatal airway safety bundle including a dedicated airway response team, emergency pager, airway cart, specialized scopes, monitors and tracheostomy
tray. After each emergency, data was collected using Emergency Tracking Form and included response times, communication between all team members, type of equipment used and emergency airway outcomes.
RESULTS: Over a 3 years, the airway response team was activated approximately 80 times, with average response time of 5.5 minutes. The airway emergency cart was at the bedside 100% of the time. Critical
communication between team members was noted > 92% of the time. Flexible laryngoscope was used in 78% of airway emergencies and resolved by repeat tracheal intubation (>98%), using a Miller, (>60%) or
Benjamin laryngoscope (~35%). 98% of airway emergencies were resolved in the NICU. There were no bedside airway related deaths. Response times improved during the subsequent year.
CONCLUSIONS: A multi-disciplinary airway emergency response team is essential in a N/IICU where airway referrals are common. Having a specialized airway team with specific equipment immediately available
including commonly used neonatal bronchoscopes, specialized laryngoscopes and viewing monitors can leads to a seamless resolution of an otherwise disastrous emergency.
Filename: 751402
Presenting Author: Julie I. Leviter, MD
Department/Institution/Address: 111 Park Street, Apt 11P, New Haven, CT, 06511, United States
Phone: 516-840-0073
Fax:
Title: Is a Haptic-Based Simulation Interface More Effective Than Computer Mouse-Based Interface for Neonatal Intubation Skills-Training?
Julie I. Leviter1, Marc Auerbach1, Candace N. Mannarino1, Sweta Bhargava1 and Anup Agarwal1. 1Pediatrics, Yale University School of Medicine, New Haven, CT.
BACKGROUND: Technology enhanced simulators are increasingly being used for procedural training. Haptic simulators provide a sense of touch by applying forces, vibrations and a 3-dimensional (3D) motion
sensor. Haptic interfaces have been incorporated into various procedural skill simulators with limited data describing their efficacy compared to other interfaces.
OBJECTIVE: To compare the efficacy of a 3D haptic interface to a 2D computer mouse interface for neonatal intubation training.
H1: A haptic interface is more effective for procedural skills training than a computer mouse interface.
H2: Completion of a computer screen-based simulation training module results in improved intubation procedural skills.
DESIGN/METHODS: 45 participants were randomized to either a haptic group or a computer mouse group to complete an identical screen-based training session. Participants completed pre- and post-training
surveys (knowledge, attitude, and satisfaction) and intubation procedural skills assessments (time and number of attempts to successfully intubate + rating of vocal cord visualization using the Cormack-Lehane scale).
RESULTS: The demographics, training and experience were similar in both groups. There was no significant difference in the decrease in attempts (0.67 vs 1.24, p=0.352) in the computer mouse vs haptic groups.
There was no significant difference in the improvement in skills, knowledge, attitudes or user satisfaction between the two groups post-training. There was a significant improvement in number of attempts (2.89 vs
1.96, p<0.05) and the percent of subjects intubating in <30sec (22% vs 27% p=0.021) between pre and post training performance in the study population as a whole.
CONCLUSIONS: A 3D haptic interface did not have an advantage over a 2D computer mouse interface in terms of skills, knowledge, attitude, or satisfaction of trainees learning neonatal intubation. Overall simulation
training resulted in improved intubation efficiency and time.
Filename: 752221
Presenting Author: M. Katherine Henry, MD
Department/Institution/Address: General Pediatrics, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, CHOP North - 1550E, Philadelphia, PA, 19104, United States
Phone: 215-531-2514
Fax:
Title: Factors Associated with Discharge from the Emergency Department Following Diagnosis of Physical Abuse in Young Children
M. Katherine Henry1, Joanne N. Wood2, Kristina B. Metzger3, Konny H. Kim3, Chris Feudtner1 and Mark R. Zonfrillo2,4. 1Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia,
PA; 2PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA; 3Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA and 4Division of Emergency Medicine,
The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Emergency medicine physicians play a key role in identifying injuries from abuse and determination of a safe disposition for the abused child. This decision is a complex process based on both
medical and psychosocial assessments of risk. The proportion of children diagnosed with abuse who are discharged and what factors influence these decisions remain unknown.
OBJECTIVE: To describe the disposition of young children diagnosed with physical abuse in the emergency setting and to identify factors and potential disparities associated with the decision to discharge these
patients.
DESIGN/METHODS: We performed a retrospective study of children < 2 years diagnosed with physical abuse in the 2006-2011 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample.
National estimates were calculated accounting for the complex survey design. Focusing on only those children who were discharged or admitted, we developed a hierarchical logistic regression model identifying
patient and institutional-level factors associated with discharge.
RESULTS: Of the 32,913 children with physical abuse, 51.3% were discharged, 41.8% were admitted, 3.9% were transferred, and 0.3% died. Factors associated with discharge are summarized below. There were
notable differences in the odds of discharge by payor type, with the publically insured more likely to be admitted and those self-pay more likely to be discharged compared to the privately insured.
Table: Factors Associated with Discharge
Characteristic
OR (95% CI)
Age (years)
<1
Referent
>=1
2.20 (1.87-2.57)
Sex
Male
Referent
Female
1.24 (1.07-1.43)
Payor
Private
Referent
Public
0.46 (0.36-0.59)
Self Pay
1.65 (1.12-2.45)
No charge, other, missing
0.52 (0.34-0.81)
Injury Severity
None
Referent
Mild
0.71 (0.60-0.84)
Moderate
0.03 (0.02-0.04)
Severe
0.01 (0.00-0.02)
Trauma Center
No
Referent
Yes
0.31 (0.22-0.44)
Volume of young children seen
Low
Referent
Medium
0.55 (0.39-0.77)
High
0.37 (0.20-0.68)
CONCLUSIONS: The majority of young children diagnosed with abuse were discharged. The notable disparity in disposition by self-pay status may suggest that self-pay status is associated with a different risk
assessment by the treating provider or a true disparity due to concerns for reimbursement and merits further study.
Filename: 750563
Presenting Author: Caitlin A. Farrell, MD
Department/Institution/Address: Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States
Phone: 978-290-1034
Fax:
Title: County-Level Poverty and Child Abuse Fatality Rates in the United States
Caitlin A. Farrell1, Eric W. Fleegler1, Celeste R. Wilson3, Cindy W. Christian2 and Lois K. Lee1. 1Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; 2Department of Pediatrics, The Children's
Hospital of Philadelphia, Philadelphia, PA and 3Department of Medicine, Boston Children's Hospital, Boston, MA.
BACKGROUND: Individual poverty has long been identified as a risk factor for child abuse. Community-level poverty also negatively impacts a variety of health outcomes. The relationship between community poverty
and fatal child abuse is not as well defined.
OBJECTIVE: We sought to evaluate the association between county-level poverty and rates of fatal child abuse in the U.S.
DESIGN/METHODS: This is a retrospective analysis of child abuse fatalities in U.S. children 0-4 years old from 1999-2010. Fatality data were obtained from the CDC Compressed Mortality Files, which include all U.S.
deaths, coded by county. ICD-10 cause of death codes for assault identified child abuse fatalities. Population statistics, including county poverty concentration, were from the U.S. Census. We calculated national
fatality rates for each year. County poverty concentration was categorized by percent of the population living below the federal poverty level for each year: 0-4.9%, 5-9.9%, 10-19.9%, and >20%. We calculated child
abuse fatality rates for each county poverty category. We performed a multivariate Poisson regression to analyze poverty as a risk factor for child abuse fatalities, controlling for race (as percent of black children in the
county) and year.
RESULTS: Between1999-2010, 7,936 children 0-4 years old were fatally abused. Forty-eight percent (3,831) were less than 1-year-old, 56% (4,449) were male, and 58% (4,655) were white.
Child Abuse Fatality Rates by Poverty Category (per 100,000 Children)
Total
<1yo 1-4yo Male Female White Black
Total
3.2
7.7
2.1
3.5
2.9
2.5
6.9
1 (0-4.9%)
1.3
4.1
0.6
1.3
1.2
1.1
4.2
2 (5-9.9%)
2.3
5.6
1.4
2.4
2.1
1.9
5.4
3 (10-19.9%)
3.5
8.4
2.3
3.9
3.1
2.7
7.4
4 ( >20%)
4.1
9.4
2.7
4.4
3.7
3.0
6.3
Poverty Category
In the multivariate Poisson regression analysis, increasing poverty concentration was associated with increasing incidence rate ratios (IRR) for fatal abuse, with the highest poverty category counties having nearly
twice the IRR compared to the lowest poverty category (adjusted IRR 1.89, 95% confidence interval (CI) 1.51-2.38).
CONCLUSIONS: Higher county-level poverty is associated with increased rates of death from child abuse, although child abuse fatalities exist in all socioeconomic groups.
Filename: 754167
Presenting Author: Kristine Fortin, MD MPH
Department/Institution/Address: Pediatrics, Children's Hospital of Philadelphia, 34th Street anf Civic Center Boulevard, 12th NW Tower Suite 55, Philadelphia, PA, 19104, United States
Phone: 267-426-3111
Fax:
Title: Characteristics of Long Bone Fractures in Children with Medical Conditions Associated with Osteopenia
Kristine Fortin1, Gina Bertocci2, Jennifer Nicholas3, Soyang Kwon3 and Mary Clyde Pierce3. 1Children's Hospital of Philadelphia, Philadelphia, PA; 2Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL and
3
University of Louisville, Louisville, KY.
BACKGROUND: Knowledge of fracture characteristics in children with osteopenia can help clinicians differentiate abuse from accidents or medical causes. Many prior studies of osteopneic children do not detail
fracture morphology or region of the long bone fractured.
OBJECTIVE: Describe fracture morphology and affected long bone region in children with osteopenia. Evaluate if fracture characteristics vary by underlying medical condition.
DESIGN/METHODS: Study of 81 patients with 216 long bone fractures from a single pediatric hospital. Inclusion criteria were known medical condition associated with osteopenia, age <18 years and ≥1 fracture.
Demographic and clinical features were extracted. A pediatric radiologist reviewed films to determine morphology and affected long bone region.
RESULTS: Underlying medical condition and clinical presentation at time of fracture N=216:
N (%)
Underlying diagnosis
45 (20.8)
Genetic connective tissue disease
54 (25.0)
Metabolic bone disease
55 (25.5)
Neurological disorder
62 (28.7)
Other chronic disease
Mobile
90 (41.7)
Yes
122 (56.5)
No
4 (1.8)
Unknown
Reason for imaging
71 (32.9)
Abnormal symptom
68 (31.5)
Trauma incident
59 (27.3)
Unrelated to fracture, incidental finding
18 (8.3)
Unknown
Bruising
16 (0.7)
Swelling
69 (31.9)
Deformity
28 (13.0)
No known overt trauma in 45.4% of cases. Bones fractured were: femur 33.3%, tibia 22.2%, humerus 13.4%, radius 12%, fibula 11.6% and ulna 7.4%. Regions most commonly fractured were diaphysis-middle third
23.4%, distal metadiaphysis 23.4%, distal metaphysis 12.4%, diaphysis-distal third 11.6% and diaphysis-proximal third 9%. Most prevalent fracture morphologies were transverse 35.7%, spiral/oblique 17.6%, buckle
17.1%, greenstick 7.9% and comminuted 6.5%. There were no classic metaphyseal lesions. Fracture morphology varied by underlying condition (p<.001):
Diagnosis
Transverse (%) Spiral/oblique (%) Buckle (%) Greenstick (%) Comminuted (%) Other (%)
Connective tissue
37.5
32.5
2.5
2.5
15.0
10.0
Metabolic
52.9
19.6
13.7
7.9
5.9
0
Neurologic
24.1
20.4
22.2
13.0
7.3
13.0
7.1
28.6
7.1
1.8
17.9
Other chronic disease 37.5
CONCLUSIONS: Fractures occurred most commonly in distal metadiaphyses and mid-diaphyses of osteopenic bones. >1/3 of fractures were transverse. Transverse fractures were most common in all categories of
underlying diagnoses.
Filename: 751546
Presenting Author: Aimee Alphonso
Department/Institution/Address: 100 York Street, Suite 1F, New Haven, CT, 06511, United States
Phone: 2037377433
Fax:
Title: Development of a Checklist To Evaluate EMS Providers' Ability To Detect Child Abuse
Aimee Alphonso1, Gunjan Tiyyagura1, Kyle Bilodeau1, Marc Auerbach1 and Kirsten Bechtel1. 1Pediatrics, Yale University School of Medicine, New Haven, CT.
BACKGROUND: Emergency medical services (EMS) providers may be the only members of the healthcare team who are both witnesses to a potential abuse scene and mandated reporters to Child Protective
Services (CPS). However, EMS providers receive minimal training about child abuse (CA) and make few reports to CPS.
OBJECTIVE: To develop a checklist to evaluate EMS providers' abilities to detect CA during a simulated child abuse scenario and to provide evidence of the checklist's validity and reliability.
DESIGN/METHODS: On the basis of clinical experience and published literature, we created a preliminary checklist consisting of behaviors important for screening an infant for CA. The checklist was iteratively
adapted over 3 rounds of Delphi review based on the ratings and feedback from 6 content experts. To assess the checklist's inter-rater reliability and construct validity, 3 independent raters used the modified checklist
to review the videos of 28 participants in a simulation scenario of abusive head trauma in an infant.
RESULTS: The final checklist consisted of 24 items with trichotomous scoring (done, not done, or not applicable). Of 28 participants, 14 (50%) detected that the infant was abused in the simulated scenario.
Participants who did detect CA did not differ significantly from those who failed to detect CA in terms of training level (EMT-B or paramedic), past experience with CA reporting, or self-reported confidence in detecting
CA. However, completion of items in the “exposure” category of the checklist was associated with detection of CA (p<0.05). The overall agreement (inter-rater reliability) of the three raters was 0.70 (0.61-0.80 indicate
substantial agreement) using Light's kappa.
Exposure Tasks1
Frequency of Task Completion
P value2
Detectors of CA, n/N (%)
Non-Detectors of CA, n/N (%)
Exposes Posterior Torso
10/14 (71)
1/14 (7)
<0.001
Exposes Entire Head and Face
11/14 (79)
4/14 (29)
0.008
Inspects Exposed Areas for Signs of Abuse
14/14 (100)
0/14 (0)
<0.001
1Signs
of inflicted injury located on maniken's face and posterior torso; 2Calculated using Pearson's Χ2 test
CONCLUSIONS: The final checklist demonstrated strong content validity and substantial inter-rater reliability. Detection of CA was independent of provider type, confidence, or experience level. Teaching prehospital
providers to expose pediatric patients on examination would likely better enable them to detect signs of CA.
Filename: 751326
Presenting Author: Gunjan Tiyyagura
Department/Institution/Address: 100 york Street Suite 1F, New Haven, CT, United States
Phone: 203-464-6343
Fax:
Title: Understanding EMS Providers' Experiences with Child Abuse and Neglect (CAN)
Gunjan Tiyyagura1, Marcie Gawel1, Jeannette Koziel1, Aimee Alphonso1, Kyle Bilodeau1 and Kirsten Bechtel1. 1Pediatrics, Yale University School of Medicine, New Haven, CT.
BACKGROUND: EMS providers may be the first healthcare providers to witness CAN on the scene, yet receive minimal training with respect to detection of CAN and make few reports of suspected CAN to child
protective services.
OBJECTIVE: To explore barriers and facilitators to detection, evaluation, and reporting of CAN by EMS providers
DESIGN/METHODS: EMS providers performed in a simulated case of infant abusive head trauma prior to participating in one-on-one semi-structured qualitative debriefs. Researchers independently coded transcripts
from the debriefing and then collectively refined codes and created themes. Data collection and analysis continued until thematic saturation was achieved after 28 EMS providers. Videotaped simulation data was
collected.
RESULTS: Barriers to recognizing CAN included limited experience with pediatrics and CAN, accepting parents' stories, lack of CAN awareness, and limited time on scene. In contrast identifying red flags such as
noting skin bruising facilitated recognition of CAN. Barriers to reporting included fear of being wrong, fear of parental reactions, and working in a fast-paced setting. In contrast, facilitators to reporting included
recognition of mandated reporter role, sharing a mental model with peers, previous experience with reporting to and working with law enforcement.
Providers described 3 key tasks when caring for a patient thought to be maltreated: Medically managing the patient, which included assessment of the patient's airway, breathing, and circulation and management of
the chief complaint, followed by evaluation for CAN; Evaluating the scene and family interactions for signs of CAN; and Creating a safety plan, which included bringing a child safely to a hospital, keeping
distance from the potential abuser, calling police for support and not confronting the caregiver.
When triangulating the debriefs with the videotaped data, CAN detection in the simulation correlated with exposing the skin of the manikin (and recognizing red flags) but was independent of provider field experience
or past experience with CAN.
CONCLUSIONS: EMS providers have a unique vantage point in detecting CAN but have limited time to screen for CAN. Focused education on recognition of signs of physical abuse, scene safety and evaluation and
real-time decision support may improve detection of CAN in the pre-hospital setting.
Filename: 751265
Presenting Author: Huma Shaikh, MD
Department/Institution/Address: Pediatric Emergency Medicine, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY, 14222, United States
Phone: 816-352-2516
Fax:
Title: A National Survey of Practice Patterns in the Management of Children with Normal Neurological Exam Being Evaluated for Child Abuse
Huma Shaikh1, Brian Wrotniak1 and Paula Mazur1. 1Pediatric Emergency Medicine, Women and Children's Hospital of Buffalo, Buffalo, NY.
BACKGROUND: Incidence of abusive head trauma is estimated at 17/100,000 children in the first 2 years of life. AAP guidelines recommend that when multiple or suspicious fractures are found, a complete skeletal
survey should be performed in children <2 years and head imaging may be considered. Although there are recommendations, there are no strict protocols developed and thus there is great variation in practice
patterns among medical professionals across the nation.
OBJECTIVE: Describe the current practice patterns regarding the workup of suspected child abuse in neurologically stable patients.
DESIGN/METHODS: Online survey was developed with 5 case scenarios based on real life cases that had head CTs done, describing H&P of neurologically stable patients <2 years old that typically present to the
acute care setting with signs/symptoms that raise suspicion of child abuse. A convenience sample of physicians practicing in Pediatric Emergency Medicine, Child Abuse Specialists or Pediatric Hospitalists in the
United States were surveyed. Email addresses were obtained using ACGME lists of fellowship/residency programs.
RESULTS: 258 physicians responded to the survey representing 36 states. 35% were male, 76% Caucasian and 12% Asian, 75% were attendings, 50% practice in PEM, 50% work in ERs of tertiary children's
hospitals and 97% in academic settings. In 3 of the case scenarios presented, >69% indicated they would do head imaging (patients aged 2, 5, 18 months with other injuries). In 1 case where there was suspicion of
child abuse in a sibling, 50% wanted head imaging. In the last case in a 21 month old with a fall at babysitters and a humerus fracture, 87% did not want any head imaging. Subspecialists were more likely to order
head CT in 3/5 cases than general pediatricians (p<0.05). Consultants were more likely to order head MRI in the same 3/5 cases than ER physicians or hospitalists (p<0.01).
CONCLUSIONS: There are large variations in the workup/diagnosis of occult head injury in cases of suspected child abuse. This indicates that there is an overall discrepancy between physicians that may be based
on level of training and setting of daily practice. There needs to be further research in the necessity of head imaging and CT use in these cases in order to develop a unified approach in conjunction with the AAP
guidelines.
Filename: 751439
Presenting Author: Panagiotis Kratimenos
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Effect of Scr Kinase Inhbition on the Expression of Second Mitochondrial Activator of Caspase (smac) Protein After Hypoxia in the Piglet Brain
Panagiotis Kratimenos1, Nandita Mandhani2, Waseem Akhter3, Jane McGowan1 and Maria Delivoria-Papadopoulos1. 1Dept. of Pediatrics, Drexel University and St. Christopher's Hospital for Children, Philadelphia, PA
and 2Pediatrics, St. Luke's Hospital, Bethlehem, PA.
BACKGROUND: Smac/DIABLO (direct inhibitor of apoptosis binding protein) are mitochondrial proteins that when present in the cytosol, neutralize the effect of cytosolic inhibitor of apoptosis proteins on caspases
and make the cell more prone to apoptosis. We have shown that cerebral tissue hypoxia results in increased expression of Smac /DIABLO in the cerebral cortex of newborn piglets. Previously we have also shown that
hypoxia results in increased activation of Src kinase in the newborn piglets brain.
OBJECTIVE: The present study tests the hypothesis that hypoxia-induced increased expression of Smac/DIABLO in the cytosolic fraction of the cerebial cortex of newborn piglets is Src kinase mediated.
DESIGN/METHODS: Piglets were divided into normoxic (Nx, n=3), hypoxic (Hx, n=3), and hypoxic pretreated with Src kinase inhibitor PP2 (4-amino-5-(4-chlorophenyl)-7-(dimethylethyl)pyrazolo[3,4-d] pyrimidine;
1mg/kg i.v.) (Hx+PP2, n=3). Hypoxia was induced by FiO2 to 0.07 for 1 hr. Selective Src kinase inhibitor was administered 30 min prior to hypoxia. Hypoxia was documented by levels of ATP and phosphocreatine
(PCr). Cytosolic fractions were isolated and the expression of Smac/DIABLO was determined by Western blotting. Proteins were separated on 10% SDS-PAGE and probed with specific anti-Smac/DIABLO antibody.
Protein bands were visualized by enhanced chemiluminescence and optical density expressed as OD/mm2.
RESULTS: The results indicate that the expression of Smac/DIABLO increased in the hypoxic group. Administration of the Src kinase inhibitor PP2 prior to hypoxia prevented the increase of Smac/DIABLO expression
in the cytosolic fraction of the cerebial cortex during hypoxia.ATP (µmoles/g brain) was 4.4±0.4 in Nx, 1.57±0.3 in Hx and 1.7±0.4 in Hx+PP2. PCr (µmoles/g brain) was 3.5±0.2 in Nx, 1.3±0.3 in Hx and 1.2±0.3 in
Hx+PP2. Density (OD/mm2) of Smac/DIABLO protein was 198.13±14.37 in Nx, 273.50±25.14 in Hx (p<0.05 vs Nx) and 201±6 in Hx+PP2 (p<0.05 vs Hx) group.
CONCLUSIONS: The data show that hypoxia-induced increased expression of Smac/DIABLO in the cytosolic fraction of the piglet brain is Src kinase mediated. We propose that since Src kinase activation during
hypoxia results in disruption of mitochondrial membrane integrity and causes the leak of proapoptotic proteins into the cytosol, the inhibition of this enzyme during hypoxia may be neuroprotective.
Filename: 751430
Presenting Author: Nandita Mandhani
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Effect of Concurrent Hypothermia and Inhibition of Caspase-9 on Caspase-3 Activity after Hypoxia-Ischemia in the Cerebral Cortex of Newborn Piglets
Nandita Mandhani1, Shadi Malaeb2, Tahlar McIntosh2, Siba A. Islam2 and Maria Delivoria-Papadopoulos2. 1Dept. of Pediatrics, Albert Einstein Medical Center, Phila, PA and 2Dept. of Pediatrics, Drexel University and
St. Christopher's Hospital for Children, Phila, PA.
BACKGROUND: Hypothermia (HT) is used to treat newborn infants with hypoxic ischemic (HI) encephalopathy but neurologic outcome of survivors remains guarded. We have previously shown increased activation of
caspase-3 and -9 enzymes mediators of apoptosis after HI. We have also shown that administration of caspase-9 inhibitor prior to HI prevented HI-induced caspase-3 activation. We also showed that HT attenuates
caspase-3 activation post-HI, indicating that there is further neuroprotection by inhibiting caspase-9 post-HI.
OBJECTIVE: The present study test the hypothesis that concurrent administration of a selective caspase-9 inhibitor, LEHD-fmk, with hypothermia post-HI will augment neuroprotection compared to hypothermia alone.
DESIGN/METHODS: Twenty ventilated 2-3 days old piglets were exposed to HI [FiO2 0.07 for 1 hr and hypotension (40% decrease in systolic BP)], then returned to FiO2 0.21 to restore O2 and BP. After 1 hr of
hypoxia, LEHD-fmk (leu-glu-his-asp-fluoromethylketone;10 µg/kg, i.v.) or saline were administered. Piglets were then cooled to 33ºC (HI-HT) or remained at normal body temperatures for 4 hrs (HI-NT4h). Caspase-3
activity (nmoles/mg protein/hr) was determined spectrofluorometrically and compared to nomroxic (Nx) controls.
RESULTS: Caspase-3 activity (M±SEM) was 54.2±0.7 in Nx (N=4), 105.4±4.2 acutely following HI (HI-0h; N=4; p<0.05 vs Nx) and 80.7±2.1 in Hx+NT4h (N=3; p<0.05 vs HI-0h and Nx). Caspase-3 activity was
43.2±0.0 in Nx-HT (N=2; p=NS vs Nx), 53.2±1.7 in HI-HT piglets (N=3; p<0.05 vs HI-NT4h) and 20.7±2.9 in HI-HT piglets treated wtih LEHD-fmk post-HI (N=3; p<0.05 vs H-NT4h, Hx-HT and Nx-HT). The data show
that HI-induced caspase-3 activity was reduced by 35% with HT and by 74% with concurrent administration of HT and caspase-9 inhibitor.
CONCLUSIONS: Hypothermia reduces caspase-3 activation in the piglet brain following HI. Caspase-3 activity was partially reduced with HT after HI compared to NT, whereas caspase-3 activity was completely
inhibited with concurrent administration of HT and an inhibitor of caspase-9. Caspase-9 is a key mediator of the intrinsic pathways of apoptosis that activates caspase-3. We propose that hypothermia partially inhibits
pathways of apoptosis and that concurrent administration of HT and caspase-9 inhibitor provides an opportunity to augment neuroprotection by hypothermia following HI.
Filename: 755354
Presenting Author: Cynthia F. Bearer, MD, PhD
Department/Institution/Address: Pediatrics, University of Maryland School of Medicine, 110 S. Paca St., 8th Floor, Baltimore, Maryland, 21211, United States
Phone: 410-328-6003
Fax: 410-328-1076
Title: Choline Ameliorates Deficits in Balance Caused By Acute Third Trimester Equivalent Ethanol Exposure
Cynthia F. Bearer1, Kristin A. Wellmann1, Ningfeng Tang1, Min He1 and Sandra M. Mooney1. 1Pediatrics, University of Maryland School of Medicine, Baltimore, MD.
BACKGROUND: Fetal alcohol spectrum disorder (FASD) is estimated to occur in 1% of all live births. Fetal alcohol syndrome, the severe end of the spectrum, is present in 2 - 7%. The development of the cerebellum
is vulnerable to the toxic effects of alcohol in all three trimesters. Adults and children with FASD have cerebellar hypoplasia and developmental deficits associated with cerebellar injury. Choline is an essential nutrient
and precursor for acetylcholine, phospholipids, methionine and 1-methyl donors. Most diets in the USA are choline deficient, thus pregnant women are at risk for choline deficiency. In rats, choline given either
concurrently with or following alcohol exposure, reduces alcohol-induced neurobehavioral deficits, but not those associated with cerebellar function. Our preliminary data show reduction in the biochemical effects of
acute alcohol exposure by prior supplementation with choline.
OBJECTIVE: Our objective was to determine if choline supplementation prior to alcohol exposure would ameliorate the impact of ethanol on cerebellar function.
DESIGN/METHODS: Pregnant C57Bl6/J mice were placed on a choline deficient diet on embryonic day 4.5 to mimic human deficiency. On postnatal day 2 (P2), pups were pseudorandomly assigned to one of 8
treatment groups: choline (C) or saline (S) from P2-6, 6 g/kg of ethanol (E) or intralipid (I) on P6, C or S from P7-20. Blood alcohol concentration (BAC) was determine 2 and 4 hours after the ethanol treatment. On
P30, cerebellar function was tested using the dowel crossing test. Six males and six females per group were tested.
RESULTS: BAC was 686+44 mg/dL and 581+33 mg/dL at 2 and 4 h post ethanol treatment respectively. For the dowel crossing test, a two way ANOVA on the total distance crossed showed that females cross
significantly longer distances than males (F1,80 = 4.749; p=0.032), and that there was a significant effect of group (F7,80 = 13.744; p<0.001). SIS animals crossed a significantly longer distance than SES or SEC
animals (p=0.021 and 0.041, respectively). In both males and females an a priori planned pairwise comparison showed that CES animals crossed significantly longer distances than SES or SEC (p=0.026 for both).
CONCLUSIONS: This is the first study to show that choline ameliorates ethanol induced cerebellar dysfunction when given before ethanol exposure. Choline fortification of common foodstuffs may reduce the
incidence of FASD.
Filename: 755418
Presenting Author: Cynthia F. Bearer, MD, PhD
Department/Institution/Address: Pediatrics, University of Maryland School of Medicine, 110 S. Paca St., 8th Floor, Baltimore, Maryland, 21211, United States
Phone: 410-328-6003
Fax: 410-328-1076
Title: Choline Ameliorates Ethanol Induced L1 Cell Adhesion Molecule Dysfunction In Vivo
Ningfeng Tang1, Min He1 and Cynthia F. Bearer1. 1Pediatrics, University of Maryland School of Medicine, Baltimore, MD.
BACKGROUND: Fetal alcohol spectrum disorder is a public health concern with 1% of all live births affected. Choline has been shown to ameliorate neurobehavioral deficits following third trimester equivalent ethanol
exposure in rats. L1 cell adhesion molecule (L1), a protein critical for the development of the central nervous system, is a target for ethanol. L1 undergoes tyrosine phosphorylation, tyrosine dephosphorylation and
traffics through lipid rafts, microdomains of the plasma membrane, in order to promote neuronal plasticity. Ethanol inhibits these processes both in vitro and in vivo. Choline supplementation of cerebellar granule
neurons 24 h prior to ethanol exposure ameliorates the redistribution of L1 into lipid rafts in vitro. Human diets are deficient in choline.
OBJECTIVE: We sought to determine if choline supplementation of rat pups would ameliorate the impact of ethanol on L1 redistribution to lipid rafts in cerebellum in vivo.
DESIGN/METHODS: Timed mated pregnant rats were placed on a choline deficient diet on gestational day 4 to mimic human choline deficiency. From postnatal day (P) 2-6, pups were treated with 1.88 mg choline
subcutaneously or an equivolume of saline. On P6, pups were given two doses of 3 g/kg of ethanol or intralipid 2 h apart, and sacrificed 2 h later. Lipid rafts were isolated by sucrose density centrifugation, and L1
quantified in lipid rafts and non-lipid rafts by immunoblot.
RESULTS: Ethanol significantly increases the proportion of L1 in lipid rafts. Choline supplementation significantly reduces this effect.
Figure 1. Representative immunoblot of L1 in lipid raft (LR) and non-lipid raft (N) pools from animals treated with: suckle control (Con), saline (S), S + ethanol (E), choline, and both choline and E. Bar graph: Mean +/SD of L1 proportion in lipid rafts. *saline vs saline + E, p<0.01; **choline + E vs saline + E, p<0.01, 2-tailed paired t-test.
CONCLUSIONS: Choline supplementation reduces the impact of ethanol on L1. Choline fortification of diet may reduce the morbidity of prenatal alcohol exposure.
Filename: 751242
Presenting Author: Carmina Erdei, M.D.
Department/Institution/Address: Pediatrics (Neonatology and Developmental-Behavioral Pediatrics), Floating Hospital for Children at Tufts Medical Center, 800 Washington St., #44, Boston, MA, 02111, United
States
Phone: (617) 636-8366
Fax: (617) 636-5621
Title: Early Systemic Inflammation and Risk for Positive Autism Spectrum Disorder Screening
Carmina Erdei1, Robert M. Joseph2, Raina N. Fichorova3,4, Elizabeth N. Allred4,5, Janice Ware4,6, T. Michael O'Shea7, Karl C.K. Kuban8, Olaf Dammann9 and Alan Leviton4,5. 1Pediatrics, Floating Hospital for Children at
Tufts Medical Center, Boston, MA; 2Department Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA; 3Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and
Women's Hospital, Boston, MA; 4Harvard Medical School, Boston, MA; 5Department of Neurology, Boston Children's Hospital, Boston, MA; 6Department of Psychiatry, Boston Children's Hospital, Boston, MA;
7
Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC; 8Department of Pediatrics, Boston University, Boston, MA and 9Department of Public Health and Community Medicine, Tufts University
School of Medicine, Boston, MA.
BACKGROUND: Extremely Low Gestational Age Newborns (ELGANs) appear to be at increased risk for early systemic inflammation, and for autism spectrum disorders (ASD) identified years later.
OBJECTIVE: To evaluate if these two phenomena are linked.
DESIGN/METHODS: The concentrations of 25 inflammation-related blood proteins were measured in blood specimens obtained close to days 1, 7, and 14 after birth from infants born before the 28th week of
gestation. The parents of 646 of these children completed both a Child Behavior Check List (CBCL) and a Modified Checklist for Autism in Toddlers (M-CHAT) at 2 years.
RESULTS: Of the 25 proteins examined, none had a concentration in the top quartile for gestational age on more than one day that was significantly associated with increased risk for having a positive ASD screen.
Elevated day-7 concentrations of VEGF-R2 and ICAM-1 were associated with a 1.6 and a 1.8-fold, respectively, increased risk of having a positive M-CHAT. Elevated concentrations of CRP, MCP-4, and MIP-1B on
day 1, I-TAC on days 1 and 7, and MMP-1 on day 14 were associated with 50-60% reduced risk for a CBCL-defined pervasive developmental problem. Elevated concentrations of CRP, myeloperoxidase, I-TAC, and
ICAM-3 on day 1, and VCAM-1 on day 14 were also associated with a 50-60% reduced risk of having a positive M-CHAT. All of the above associations were statistically significant.
CONCLUSIONS: In extremely preterm born children, the risk for screening positive for ASD at 2 years is not associated with overall sustained early systemic inflammation.
Filename: 754428
Presenting Author: Praveen Chandrasekharan
Department/Institution/Address: Women and Children's Hospital of Buffalo/State University of New York , 219 Bryant Street, Buffalo, NY, United States
Phone: 7168787662
Fax:
Title: Continuous Capnography (End Tidal CO2) Monitoring During Neonatal Resuscitation
Praveen Chandrasekharan1, Munmun Rawat1, Jayasree Nair1, Sylvia Gugino1, Carmen Koenigsknecht1, Daniel Swartz1, Payam Vali1, Bobby Mathew1 and Satyan Lakshminrusimha1. 1Division of
Neonatology/Department of Pediatrics, Women & Children's Hospital of Buffalo/State University of New York at Buffalo, Buffalo, NY.
BACKGROUND: Current neonatal resuscitation program (NRP) recommends close monitoring of oxygenation using a pulse oximeter. However, there are no recommendations to monitor ventilation (CO2). Cerebral
blood flow is directly proportional to PaCO2. Continuous capnography end tidal CO2(ETCO2) monitoring may limit fluctuations in cerebral blood flow (CBF) during resuscitation of asphyxiated infants.
OBJECTIVE: To study the impact of ETCO2monitoring during and after resuscitation on cerebral blood flow in term lambs with asphyxia and meconium aspiration syndrome (MAS).
DESIGN/METHODS: 54 term lambs were asphyxiated with umbilical cord occlusion following endotracheal instillation of meconium. Gasping respirations resulted in MAS. Lambs were resuscitated as per NRP
guidelines. Positive pressure ventilation (PPV) was adjusted based on clinical observation (chest excursion) and right carotid arterial blood gases (drawn every 5 min for 30 min and every 15 min for the next 30 min) in
24 lambs (control). PPV was adjusted using continuous ETCO2monitoring in 30 lambs (capnography group). Left carotid blood flow was monitored. We aimed to maintain PaCO2between 35 to 45 mmHg.
RESULTS: Umbilical cord occlusion and meconium aspiration resulted in severe acidosis (pH 6.9±0.13 vs. 7.02±0.1; paCO2107±25 vs. 102±29 in control and capnography groups respectively). Maximum and
minimum PaCO2and carotid blood flow between 5 and 60min of age showed significantly higher fluctuation in control group compared to capnography group.
There was significant correlation between ETCO2and PaCO2(R=0.7,p<0.001), between PaCO2and carotid flow (R=0.52, p<0.001) and between ETCO2and carotid blood flow (R=0.5, p<0.001).
CONCLUSIONS: Using capnography during resuscitation with constant ventilation changes limits fluctuations in PaCO2 and CBF during and after neonatal resuscitation for birth asphyxia and may potentially limit brain
injury.
Filename: 752688
Presenting Author: Deidre M. St. Peter, B.S.
Department/Institution/Address: Pediatrics, 110 S. Paca St, 8th Floor 8-S-163, Baltimore, MD, 21201, United States
Phone: 4103286003
Fax: 4103281076
Title: Defining Hypotension in Premature Neonates: Is 30 Better?
Deidre M. St. Peter1, Christiana L. Gandy1, Natalie L. Davis1 and Suma B. Hoffman1. 1Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD.
BACKGROUND: In the premature neonate, there is no consensus regarding normal blood pressure. The most common definition used is a mean arterial blood pressure(MAP) less than the gestational age(GA).
Recently, studies indicate that the neuroprotective mechanism of autoregulation is lost below a MAP of 30 mmHg.
OBJECTIVE: This study aims to compare 2 definitions of hypotension: MAP < GA (A) or MAP < 30(B).
DESIGN/METHODS: A single center 3 year retrospective chart review was conducted on inborn infants 24-32 wks gestation. Demographic and clinical data including blood pressure parameters were collected for the
first 72 hrs of life. Patients were determined to be hypotensive if they met the preset definition for over 1 consecutive hour. For each definition of hypotension, differences in hypotensive and normotensive infants were
evaluated using T-test and Chi-square analysis for continuous and categorical data respectively. Further, logistic regression was used to determine independent predictors of composite outcome(death or
intraventricular hemorrhage(IVH) grade 3 or 4).
RESULTS: 202 patients were evaluated in the study period. 40% of patients were defined as hypotensive using definition A, 55% of patients were defined as hypotensive using definition B. The hypotensive patients in
both groups were similar in birth weight, GA, gender, Apgar scores, maternal chorioamnionitis, and antenatal steroid use
. Using both definitions, hypotension was significant for adverse outcomes, however hypotension B showed a much stronger significance for CLD, Death, and IVH
. On logistic regression, when controlling for BW, gender, antenatal steroid use, hypotension definition, and minimum blood pressure in the first 12 hrs of life, the significant predictors of the composite outcome were
GA and treatment with vasopressor therapy(OR 0.4 and 10.3 respectively).
CONCLUSIONS: Based on these results, a MAP of 30 may be a more meaningful target than MAP < GA, however given the risk of vasopressor therapy, treatment practices need to be further investigated.
Filename: 752213
Presenting Author: Jonathan P. Mintzer, MD
Department/Institution/Address: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Stony Brook Children's Hospital, HSC T11, Room 060, Stony Brook, NY, 11794-8111, United States
Phone: 631-444-7653
Fax: 631-444-8968
Title: Effects of Hematocrit Levels on Cerebral, Renal, and Splanchnic Oxygen Extraction in Very Low Birth Weight Neonates: Expanding the Scope of Near-Infrared Spectroscopy (NIRS)
Jonathan P. Mintzer1, Boriana Parvez2, Gad Alpan2 and Edmund F. La Gamma2. 1Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Stony Brook Children's Hospital, Stony Brook, NY and 2Department
of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY.
BACKGROUND: During anemia, reduced O2 content alters blood flow distribution and increases fractional tissue oxygen extraction (FTOE) to sustain O2 consumption. In preterm neonates, it is unknown whether
FTOE changes are proportional to the degree of anemia or whether these changes in O2 extraction occur similarly across various NIRS monitoring sites.
OBJECTIVE: To determine the effect of severity of anemia on cerebral, renal, and splanchnic O2 extraction.
DESIGN/METHODS: Data were collected in an observational NIRS survey of 500-1250 g neonates during the first postnatal week. Cerebral, renal, and splanchnic FTOE values were calculated using pulse oximetry
and NIRS data for hours corresponding to Hct determinations. These data were then plotted and analyzed for correlation (Pearson r) between Hct and site-specific FTOE.
RESULTS: Twenty-seven neonates underwent 116 Hct determinations during the first postnatal week. GA was 27 ± 2 wk (median ± SD) and BW was 945 ± 181 g. Hct sampling was performed from 6–221 hours of
life; median Hct was 39 ± 5 %. During blood sampling, median (IQ range) O2 saturations were 95 % (90-97), systolic BP 50 mmHg (46-58), and diastolic BP 28 mmHg (23-33). Cerebral FTOE was 0.22 ± 0.10 (median
± SD), compared to renal 0.30 ± 0.14 and splanchnic 0.59 ± 0.21. Cerebral and renal FTOE were inversely correlated with Hct levels (cerebral r = -0.369, p < 0.05; renal r = -0.420, p < 0.05). No correlation was
observed between splanchnic FTOE and Hct percent (splanchnic r = -0.105, p = NS).
CONCLUSIONS: Cerebral and renal O2 extraction increase with progressively lower Hct; an effect not evident at the splanchnic site likely owing to its signal variability or to differences in splanchnic capacity to adjust
to lower O2 delivery. We speculate that noninvasive FTOE trending may aid in understanding organ-specific responses to anemia and in identifying suitable thresholds for treating anemia in very low birth weight
neonates.
Filename: 751460
Presenting Author: Stephen Pearlman, MD, MSHQS
Department/Institution/Address: Neonatology, Christiana Care Health System, 4745 Ogletown-Stanton Road, Suite 217, Newark, DE, 19713, United States
Phone: 302 733-2410
Fax: 302 733-2602
Title: Delayed Umbilical Cord Clamping Reduces the Need for Red Blood Cell Transfusions in Infants < 1500 Grams
Stephen Pearlman1, Jeffrey Bolstridge2, Tracy Bell1, Barbara Dean1, Amy Mackley1, Gina Moore1, David Paul1, Cheryl Swift1 and Dina Viscount1. 1Christiana Care Health Services, Newark, DE and 2Philadelphia
College of Osteopathic Medicine, Philadelphia, PA.
BACKGROUND: In 2012, the ACOG and AAP released a recommendation to delay cord clamping(DCC) in infants born before 37 weeks gestation. Our institution formed an interdisciplinary team to implement this
new recommendation and to educate staff.
OBJECTIVE: To measure the impact of DCC on neonatal outcomes, principally on the need for packed red blood cell(pRBC) transfusion in infants < 1500g and associated cost savings.
DESIGN/METHODS: A interdisciplinary team comprised of a neonatologist, fellow, obstetrician, clinical nurse specialists and nurses developed a policy and educated all staff involved in delivery room care. The
program was initiated on July 1, 2013. One year after implementation we performed a retrospective cohort study of babies weighing < 1500 grams comparing a pre-implementation cohort (July 1, 2012- June 30, 2013:
cohort 1) to a post-implementation cohort (July 1, 2013- June 30, 2014: cohort 2). The data collected included incidence of DCC, pRBC transfusions, neonatal complications and balancing measures. A post-hoc
financial analysis based on charges for blood transfusions was performed.
RESULTS: There were no differences in BW, GA, Apgar scores or mortality between cohorts. Table 1 shows the impact of DCC on clinical outcomes. The need for pRBC transfusions diminished from 54% to 32%
(p=0.001) leading to a cost savings of $100,000 in the first year. There were no increases in balancing measures or neonatal complications.
COHORT 1 COHORT 2
p value
(n=136)
(n=91)
Delayed cord clamping
0.73%
72.5%
<0.001
pRBC Transfusion
54%
32%
<0.001
Admission Hypothermia
29.4%
36.3%
0.28
Ventilation at any time
69.1%
52.7%
0.012
CPAP at any time
83.8%
62.6%
<0.001
Phototherapy
85.3%
89%
0.41
Intraventricular Hemorrhage 25.0%
20.9%
0.47
Severe IVH
6.6%
0.11
Periventricular Leukomalacia 1.5%
4.4%
0.18
Patent Ductus Arteriosus
37.5%
28.6%
0.16
Early Onset Sepsis
1.5%
0%
0.29
Necrotizing Enterocolitis
2.9%
3.3%
0.88
13.2%
CONCLUSIONS: Our data demonstrate rapid, successful implementation of a program that surpasses many other published studies and represents a major change in care delivery. DCC lead to a significant decrease
in pRBC transfusions. We continue to monitor compliance with the goal of 100% for neonates without a contraindication to DCC.
Filename: 753422
Presenting Author: Tamara G. Kalhan, MD
Department/Institution/Address: Pediatrics, Columbia University Medical Center, 3959 Broadway, BHN 12-1200A, New York, NY, 10032, United States
Phone: 512-971-7679
Fax: 212-305-8796
Title: Effects of RBC Storage on Iron and Inflammatory Cytokines in VLBW Infants (BW <1250g)
Tamara G. Kalhan1, Eldad A. Hod1, Rakhee Bowker2 and Sudha Kashyap1. 1Neonatal-Perinatal Medicine and Pathology, Columbia University Medical Center, New York, NY and 2Neonatology, Northwestern University
Feinberg School of Medicine, Chicago, IL.
BACKGROUND: Increased storage timeof transfused red blood cells (RBCs) is associated with greater morbidity and mortality in hospitalized patients. The mechanisms responsible for this are not known.
OBJECTIVE: To determine the effect of storage time of transfused RBCs on non-transferrin-bound iron (NTBI) and inflammatory marker (interleukin (IL)-8 and monocyte chemoattractant protein (MCP)-1)
concentrations in very low birth weight (VLBW) infants (BW <1250g).
DESIGN/METHODS: In this ongoing prospective observational study, an interim analysis was conducted that included 19 transfusion events from 9 VLBW infants (mean BW 757g; range 474-920g). Serum NTBI, iron,
IL-8 and MCP-1 levels were measured from all transfused infants immediately before and 2-6h after each transfusion. A paired t-test was used to compare pre- and post-transfusion levels of each variable measured.
Linear regression analysis was performed to determine the correlation between the storage age of transfused RBCs on the change in NTBI, iron, IL-8, and MCP-1 concentrations.
RESULTS: Mean age of transfused RBCs was 14d (range 6-30d) and mean postmenstrual age of the infants at transfusion was 30wks (range 24-37wks). NTBI, iron, and MCP-1 levels were significantly greater after
transfusion of RBCs (p<0.05); however, no significant difference was observed in IL-8 concentrations. The storage age of transfused RBCs positively correlated with the increase in NTBI and serum iron following
transfusion (p<0.01; R2 = 0.52 and 0.46, respectively). No association between the duration of storage and changes in inflammatory markers (MCP-1 and IL-8) was observed.
CONCLUSIONS: Interim analysis of this ongoing study shows that transfusions of RBCs after longer durations of RBC storage are associated with increased NTBI and iron concentrations post-transfusion.
Furthermore, MCP-1 levels are increased following RBC transfusion; however, this increase is not associated with the storage duration. The clinical consequences of these findings remain to be determined.
Filename: 751713
Presenting Author: Kelley Z. Kovatis, MD
Department/Institution/Address: Neonatology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, United States
Phone: 6106392228
Fax:
Title: Effect of Blood Transfusions on Intermittent Hypoxia
Kelley Z. Kovatis1, Juliann M. Di Fiore2, Richard J. Martin2 and Haresh Kirpalani1. 1Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA and 2Neonatology, Rainbow Babies & Children's Hospital,
Cleveland, OH.
BACKGROUND: Apnea is associated with multisystem morbidity and mortality and may be exacerbated by anemia. Apnea is often treated with red blood cell (RBC) transfusions. Intermittent hypoxia (IH) reflects an
immature respiratory neuronal center and represents a consequence of apnea.
OBJECTIVE: To compare the number of IH episodes before and after transfusions in VLBW infants.
DESIGN/METHODS: Infants 1-6 weeks PMA, < 1000 grams; or weeks 0-6 for infants < 1500 grams were included. High resolution pulse oximeter (Masimo) with 2s sample rate, recorded saturations before and after
administered blood products (RBC, Platelets, FFP). IH is defined as saturations < 80% for ≥ 10s and < 3 minutes. Data was analyzed by customized software.
RESULTS: 17 patients with 37 transfusions were analyzed.
Grouping by GA and BW
N Mean GA (wks) # of Transfusions # of RBC Transfusions Mean CGA at Transfusion (wks)
Mean Weight at Transfusion (g)
Reciving Invasive Ventilator Support (%)
≤ 25 weeks
8 23.9
778
85.7
21
21
26.8
>25 weeks
9 26.2
16
11
26.6
1062
68.8
≤ 1000 g
16 25.0
35
30
27.5
888
77.1
>1000 g
1 27.0
2
2
29.4
1133
6.9
Number of IH events before and after transfusions were high with a median of 12.34 per hour (6.46, 18). Median saturations before and after transfusions were 91.1% (89.69, 93.47) and 91.28% (89.76, 92.94) and did
not differ (p=0.66). Number of IH events before and after transfusions were similar. Percent time with saturations <85%, <80%, and <75% did not differ.
Before Transfusion After Transfusion
Median(25th,75th)
RBC Transfusions
Median(25th,75th) P Value
#IH Events/Hr 6.3(3.2,9.6)
5.38(2.8,8.3)
0.46
%Time<85%
18.0(10.2,27.9)
15.1(9.5,27.4)
0.56
%Time<80%
8.7(3.7,14.0)
8.3(4.3,12.9)
0.50
%Time<75%
4.0(1.1,7.7)
3.9(2.2,6.1)
0.47
5.1(4.9,10.3)
0.69
Other Transfusions #IH Events/Hr 7.8(4,12.1)
%Time<85%
37.6(16.2,40.4)
16.5(14.7,10.3)
0.89
%Time<80%
11.9(9.2,19.3)
7.4 (7.2,14.9)
0.89
%Time<75%
5.4 (4.4,10.8)
4.1(3.6,5.4)
0.69
Number of IH events did not differ regardless of ventilation support (p=0.63).
CONCLUSIONS: IH is frequent. Blood products do not impact the frequency of intermittent hypoxia for hemoglobin ranging from 8.3-14.9 g/dl and platelets ranging from 33-572 thou/ UL.
Filename: 755679
Presenting Author: Paresh Pandit, MD
Department/Institution/Address: Neonatology, CHOP Newborn Care at Virtua, 100 Bowman Drive, Voorhees, NJ, 08043, United States
Phone: 16097446692
Fax:
Title: Reducing Radiation Exposure and Improving X-Ray Quality in the NICU
Christine Catts1, Linda Levy1, Kevin Graff2 and Paresh Pandit1. 1Neonatology, CHOP Newborn Care at Virtua, Voorhees, NJ and 2Radiology, Virtua Health System, Voorhees, NJ.
BACKGROUND: Neonates undergoing intensive care often receive multiple X-rays. Factors that lead to excessive radiation exposure and poor X-ray quality include: 1. Inadequate collimation resulting in an excessive
area being irradiated; 2. Artifacts obscuring relevant fields; 3. Poor positioning.
These can lead to difficulty in appropriate interpretation and a need for repeat X-rays.
OBJECTIVE: 1. Reduce radiation exposure. 2. Improve the quality and interpretability of X-rays
DESIGN/METHODS: In a Level 3 NICU, patients that had X-rays in Aug 2013 (Phase1) were identified. 50 X-rays were reviewed. The area of actual exposure was compared with the "ideal" area of exposure. The
area of excessive exposure (EE) was calculated. The presence of artifacts obscuring relevant fields and appropriate positioning was noted. These data were reviewed to assess which interventions would help improve
X-ray quality. PowerPoint presentations and poster boards were used to inform and educate X-ray technicians (to improve collimation) and nurses (to improve positioning and removal of artifacts). Another 50 X-rays
were analyzed in Phase2 (Jan 2014) and in Phase3 (June 2014). A run chart was constructed to assess changes following intervention. Outcome metrics were % decrease in irradiated area, % X-rays without artifact,
% appropriate positioning, % interpretation affected (IA).
RESULTS: The run chart (Fig) illustrates an ongoing reduction in EE following intervention. The median % EE decreased from 37% (Phase1) to 15% (Phase2), and 0% (Phase3).
Table shows a decrease in artifacts and in IA, but also in appropriate positioning.
Phase 1 Phase 2 Phase 3
Artifacts
8%
0%
Appropriate Positioning 90%
42%
88%
72%
Interpretation Affected
4%
6%
25%
CONCLUSIONS: Using a PDSA model, we have shown a sustained decrease in radiation exposure and an improvement in the overall quality of NICU X-rays. Patient safety and quality of care requires ongoing audit,
education and collaboration between various disciplines.
Filename: 750922
Presenting Author: Muoy Lim, MD
Department/Institution/Address: 2250 Clarendon Boulevard, Apt 712, Arlington, VA, 22201, United States
Phone: 301-928-2694
Fax:
Title: Reducing Unnecessary Radiation Exposure in Children Presenting to a Military Emergency Department with Head Injury - A Resident QI Project
Muoy Lim1, Katherine M. Ottolini1 and Robert Kurlantzick1. 1Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD.
BACKGROUND: The PECARN guidelines for obtaining head computed tomography (CT) in children presenting to the emergency department (ED) with head injury have been validated to identify those at very low risk
for clinically-important traumatic brain injury (ciTBI).
OBJECTIVE: To implement the PECARN guidelines in our military emergency department, where children are primarily evaluated by adult-trained ED physicians, in order to reduce unnecessary exposure to ionizing
radiation in children presenting with head injury.
DESIGN/METHODS: The Emergency Department Head CT Order Sheet was updated to include the PECARN criteria (for both children <2 and > 2 years old) as part of the required documentation. Emergency
department physicians were then educated on the proper use of the PECARN algorithms. We reviewed the charts of all pediatric patients (<18 years old) presenting within 24 hours of head injury during
pre-intervention (July 2012-October 2013, n =111) and post-intervention (November 2013-August 2014, n = 81) time periods to compare the number of unnecessary head CTs obtained.
RESULTS: The proportion of children with head injury who underwent head CT was reduced from 23% (n =25) to 16% (n = 13) after implementing the PECARN guidelines, with more physicians opting for patient
observation instead of head CT. Additionally, the ordering of head CTs when not recommended according to PECARN criteria was significantly reduced from 12% to 1% of patients (p <0.05). In those children who
underwent head CT, none had ciTBI.
CONCLUSIONS: Implementing the PECARN guidelines in our emergency department significantly reduced the unnecessary ordering of head CTs in children presenting with head injury and very low risk of ciTBI.
Filename: 750256
Presenting Author: Marcie N. Gawel, MSN
Department/Institution/Address: 100 York Street, New Haven, CT, 06511, United States
Phone: 3127142888
Fax:
Title: Infant CPR Quality in Pediatric Emergency Department: Adherence To 2010 AHA Guidelines
Marcie N. Gawel1, Sweta Bhargava1, Yedidya M. Ben-Avie1, Douglas A. Streat1 and Marc A. Auerbach1. 1Yale University School of Medicine, New Haven, CT.
BACKGROUND: Despite extensive provider training, outcomes from Cardiopulmonary Arrest (CPA) in children remain poor. Optimal cardiopulmonary resuscitation (CPR) performance is challenging due to the
low-frequency of exposure for pediatric providers.
OBJECTIVE: To determine whether highly trained inter-professional providers performing infant CPR adhere to the 2010 AHA guidelines. H1: Provider's with advanced and more recent certification will have higher
adherence. H2: Provider's with increased confidence or previous experience will have higher adherence.
DESIGN/METHODS: Providers were recruited to complete simulated CPA scenario at a large Pediatric ED. Providers reported certification status, time since last certification, confidence in adherence to AHA
guidelines and previous CPR experience via an online survey. The Laerdal Resusci Baby QCPR© was placed in ED and providers were presented a standardized case that prompted them to begin single-rescuer
CPR. Quantitative data was collected over 2 minutes and extracted from the Skill Reporter©. The CPR score was calculated using compression, ventilation and flow fraction score. Statistical analyses were performed
using SPSS.
RESULTS: 101 providers were enrolled. 100% were BLS certified, 84.2% PALS and 60.4% ACLS certified. Time since last certification was <6 months for 49.5% of the providers. 20.8% had previous infant CPR
experience. 65.3% were confident in adhering to AHA guidelines. CPR performance is reported in Table 1. The relationship between provider characteristics and CPR score is reported in Table 2.
CPR Quality
Expected
Performance
CPR score
100%
35.7 (31.4, 40.0)
Compression Rate
100-120/minute 132.3 (125.9, 138.7)
Compression Depth
≥ 40 mm
37.9 (36.7, 39.1)
Correct Hand Placement 100%
68.7 (61.8, 75.6)
Recoil
100%
70.8 (64.2, 77.4)
Compression Fraction
≥70%
61.2 (59.0, 63.4)
Ventilation Rate
6-12/minute
3.9 (3.4, 4.4)
Ventilation Volume
20- 40 ml
41.3 (36.8, 45.8)
Provider Variables
CPR Score
Certification:
Basic (BLS)
26.3
Advanced (PALS/ACLS)
36.0
p=0.006
Time Since Certification (months):
≤6
39.4
>6
32.0
p=0.091
Previous Infant CPR experience:
Yes
33.2
No
36.3
p=0.141
Confidence in adherence to guidelines:
Yes
35.1
No
36.8
p=0.359
CONCLUSIONS: The majority of highly trained inter-professional providers performing infant CPR did not adhere to the 2010 AHA guidelines. Providers with advanced certification had higher adherence.
Abstract Number: 74
Filename: 750164
Presenting Author: Son H. McLaren, MD
Department/Institution/Address: 1320 York Ave Apt 31B, New York, NY, 10021, United States
Phone: 4436181939
Fax:
Title: Effectiveness of High Fidelity Simulation on Clinical Application of the Pecarn Head Trauma Rule
Son H. McLaren1, Ilana Harwayne-Gidansky1, Kristen Critelli1, Jennifer Garnett1 and Kevin Ching1. 1Pediatrics, New York Presbyterian Hospital / Weill Cornell Medical Center, New York, NY.
BACKGROUND: Pediatric residents are expected to learn and utilize a clinical predication rule derived and validated by the Pediatric Emergency Care Applied Research Network (PECARN) to determine whether
children with head trauma need neuroimaging to identify traumatic brain injury. Medical simulation has the potential to emulate clinical encounters in an immersive learning environment without the risk to this highly
vulnerable population. However, there is limited data on the transfer of medical decision making skills learned in simulation training to patient care.
OBJECTIVE: The purpose of this study is to determine the longitudinal impact of simulation training on residents utilizing the PECARN clinical decision rule in patient care.
DESIGN/METHODS: We designed a single center, blinded prospective randomized control pilot study. After completing a pre-test, 20 interns were randomized to participate in either an immersive head trauma
simulation focused on the use of the PECARN clinical prediction rule or an unrelated simulation case on acute intracranial hypertension. To assess their ability to utilize this rule, for the next 12 months all interns, as
well as junior and senior residents, completed a structured clinical observation assessment each time they evaluated a pediatric patient with head trauma. At the end of the academic year, all interns completed a
post-test and two simulation exercises involving the PECARN head trauma rule.
RESULTS: One month after the simulation, interns in the PECARN simulation group scored a median of 24% higher compared to the control group in their ability to correctly utilize the PECARN head trauma rule. This
trend was maintained throughout the academic year, with the interns in the study group consistently scoring a median of 14-29% higher than the control group each month. Interns in the study group also performed at
a similar level as non-simulated but more experienced second and third year residents, with a median score of 71% at the end of the academic year, compared to 57% in the control group.
CONCLUSIONS: Our preliminary proof-of-concept data suggests that interns can gain clinical performance competencies qualitatively similar to that of more senior residents after participating in immersive simulation
training. It also demonstrates that one-time simulation can have long-term impact on learning that is sustained after 6 months.
Filename: 751599
Presenting Author: Jillian S. Savage, DO
Department/Institution/Address: 812 Bezel Road, Wilmington, DE, 19803, United States
Phone: 3024944491
Fax:
Title: Does the Role of a Rapid Triage Provider Improve Pain Control in an Academic Pediatric Emergency Department?
Jillian S. Savage1 and Andrew D. DePiero1. 1Emergency Department, Nemours, Wilmington, DE.
BACKGROUND: Previous work has shown that a RTP (rapid triage provider) may decrease quantifiable measures such as Emergency Department (ED) length of stay (LOS), left without being seen rates and time to
provider measurements. To date, no studies have assessed the quality of care provided by a RTP, evaluating pain control specifically.
OBJECTIVE: To determine if time of arrival to time of intravenous (IV) pain medication administration was impacted by the presence of a RTP. Secondary objectives include time of arrival to time of order placement
for IV pain medication, Emergency Department LOS and admission rate.
DESIGN/METHODS: We performed a retrospective case control study of patients requiring IV pain medications for fractures, burns, dislocations, vaso-occlusive crises and complex lacerations. All patients were
evaluated in a single suburban pediatric Emergency Department with an annual volume of approximately 50,000 visits. Patients were identified from the electronic medical record via ICD-9 codes from January to July
of 2014. Using the independent t-test, data was analyzed comparing the two groups. Patients in the control group were managed according to standard nursing driven triage process. Patients in the RTP group were
seen by the standard triage team and a RTP who may enter non-protocol orders including IV placement and IV pain medication.
RESULTS: We identified 114 patients who required IV pain medications for the above listed diagnoses. The 84 control patients and the 30 RTP patients were similar in sex, medication administered and initial pain
score. There was a statistically significant difference in age and proportion of diagnoses between each group. The primary outcome of time from arrival to pain medication administration for the RTP group as
compared to the control group was statistically significant (p=0.02) with means of 47 and 65 minutes respectively. Time of arrival to time of order placement for IV pain medication was also statistically significant
(p=<0.0001) with means of 16 and 43 minutes respectively. There was no statistically significant difference in LOS or admission rate.
CONCLUSIONS: The presence of a RTP improves pain control in the pediatric Emergency Department via more efficient order entry and subsequent rapid IV pain medication administration. LOS and admission rates
were unchanged between groups.
Filename: 753133
Presenting Author: Alena Connelly, MD
Department/Institution/Address: Pediatrics, Winthrop University Hospital, 259 1st street, Mineola, 11501, United States
Phone: 1-516-663-2288
Fax:
Title: Improvement of Door To Doctor Time in Patients With Severe Sepsis By Using Standardized Triage Screening in Pediatrics
Alena Connelly1, Jessica C. Chang1, Tanya Mokhateb-Rafii1, Claudia L. Thomas1, Robert A. Asselta1 and Maria Lyn Quintos-Alagheband1. 1Pediatrics, Winthrop University Hospital, Mineola, NY.
BACKGROUND: Evidence has shown that timely antibiotic administration is the critical determinant of survival in patients with severe sepsis. In our pediatric population with severe sepsis we have focused the process
improvement on early recognition and administration of antibiotic within the golden hour of presentation to emergency department. Interim data analysis for 2010-2012 of 23 pediatric patients with severe sepsis
showed that door to doctor time in minutes (DTD) appears to be the limiting step to intervention. Patients with DTD over 15 min (N=12) have a mean time to antibiotic of 92 min versus 53 min in those with DTD less
than 15 min.
OBJECTIVE: To improve mean time to antibiotic therapy in patients with severe sepsis by 25%. Our process measures for this project are decreasing DTD time by 25% and increasing the number of patients screened
using standardized triage tool.
DESIGN/METHODS: Primary methodology: series of 6 months PDSA cycles. First PDSA cycle we implemented standardized triage screening tool or patient with fever or hypothermia who are at high risk for sepsis or
have abnormal age based vital signs. Second PDSA with did an 1:1 reeducation of triage staff. Third PDSA included data analysis and direct feedback to front line on performance indicators. Currently we are
incorporating EMR into the process.
RESULTS: Our primary outcome measure which is the time for antibiotic administration showed sustained improvement.
The total number of patients screened for sepsis increase over time with the average DTD time decreasing from 24 to 10 minutes.
Baseline 1st PDSA 2013 2nd PDSA 2013 3rd PDSA 2014 4th PDSA 2014-now
Mean antibiotic time, minutes 134
105
77
62
61
Mean DTD, minutes
12
9
10
10
36
64
97
102
24
Number of patients screened 0
CONCLUSIONS: A comprehensive quality improvement initiative directed at decreasing DTD appears to significantly impact timeliness of antibiotic therapy in patients with severe sepsis.
Filename: 752427
Presenting Author: Steven C. Rogers, M.D.
Department/Institution/Address: Emergency Medicine, Connecticut Children's Medical Center, 282 Washington Street, Hartford, Connecticut, 06106, United States
Phone: 860-837-5435
Fax: 860-837-5442
Title: Escalating Mental Healthcare in Pediatric Emergency Departments
Steven C. Rogers1, Christine H. Mulvey1 and Jesse Sturm1. 1Department of Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT.
BACKGROUND: Mental healthcare for children has widespread funding gaps and many communities lack adequate services. Parents who perceive their child as having a mental health crisis often seek the immediate
availability of services provided in a pediatric emergency department (PED). This population presents a unique challenge to pediatric emergency medicine providers due to the high level of resources required to
provide care and ensure safety.
OBJECTIVE: To quantify the national increase in mental health visits to PEDs using the Pediatric Health Information System (PHIS).
DESIGN/METHODS: Using the PHIS database, national rates of visitation to PEDs that result in a final primary ICD-9 diagnosis of a psychiatric condition were examined. These rates were evaluated over time
nationally and by census regions, significant trends were determined by logistic regression.
RESULTS: Overall 13,204,293 visits were evaluated from 2009-2013. A rate of 11.7 mental health visits per 1000 PED visits had a psychiatric diagnosis. Visits had a mean length of stay of 2.71 days, were
approximately 51% male, with a mean age of 12.4 years. The most common ICD-9 diagnoses in this group were mood disorder (12.9%), depressive disorder (12.3%), and conduct disorder (9.3%). The national rates
of psychiatric visits increased over 40% from a low of 9.3 visits per 1000 in 2009 to peak of 13.74 visits per 1000 in 2013. Significant increases were seen across all predefined census regions.
CONCLUSIONS: There has been a significant increase in PED psychiatric volumes nationwide over the last 5 years. These visits consume vast resources in otherwise busy PEDs. Most PED care providers receive
limited formal training in psychiatric assessment; pediatric credentialing guidelines have a limited focus on emergency psychiatric training in residency or fellowship. Future areas of education, residency training, and
research should focus on improving the safety and efficiency of providing mental healthcare in the PED setting.
Filename: 751666
Presenting Author: Milani Patel, MD
Department/Institution/Address: 3544 Jerome Avenue, 2nd Floor, Bronx, NY, 10467, United States
Phone: 2012483447
Fax:
Title: Resident Documentation of Social Determinants of Health: Effects of a Teaching Tool
Milani Patel1,2, Jenna Scholnick1,2, Tanya White-Davis2, Eleanor Bathory1,2 and Sandra Braganza1,2. 1Department of Pediatrics, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY and
Department of Family and Social Medicine, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY.
BACKGROUND: Social determinants of health (SDH) significantly impact the health of children, and thus, screening for SDH is an important component of the primary care visit in underserved and poverty-stricken
communities. Resident medical curriculum should include how to effectively and comprehensively inquire about SDH. A mnemonic,“IHELLP,”- Income, Housing, Education, Literacy, Legal Status, Personal Safety- has
been used to assist in eliciting a social history which includes these SDH. However, there is limited research on how an educational intervention incorporating this tool can impact resident assessment of SDH.
OBJECTIVE: To assess the impact of a two phase educational intervention using (1) the “IHELLP” mnemonic alone and (2) in conjunction with visual reminders, on resident physician documentation of SDH.
DESIGN/METHODS: A two-phase quasi-experimental intervention was implemented with 8 residents over a 3 month period: phase 1 (P1) entailed a 3 hour teaching module describing the “IHELLP” mnemonic, SDH
content, and relevant community resources; phase 2 (P2) included posted visual reminders on a 2 x 4 card in all resident clinic rooms and laminated pocket cards for residents. Charts were reviewed, using a “yes/no”
checklist, assessing the residents' documentation of SDH. Charts were assessed at baseline (as a control) and after each intervention. Pre- and post- intervention comparisons were made using chi square analyses.
RESULTS: A total of 357 charts were reviewed: 101 charts at baseline, 143 charts after P1, and 113 charts after P2. The average age of patients was 47.2 months; 55% female, 45% male. As compared to baseline,
residents were significantly more likely to document asking about WIC benefits after P1 (40.5% vs 57.6%, p<0.01) and after P2 (40.5% vs 60.2%, p<0.01); they were also more likely to ask about food stamps (14% vs
28%, p<0.01) and about financing of current housing (4% vs 12.6%, p<0.05) after P2. There were no differences in documentation of education, legal, literacy, and personal safety issues.
CONCLUSIONS: Implementation of an educational teaching module using “IHELLP” along with visual reminders enabled residents to document SDH in concrete services such as benefits and housing. Further studies
should be done to evaluate effective teaching methods to assist residents in eliciting other, more sensitive, social determinants of health such as education, legal issues, and personal safety.
2
Abstract Number: 68
Filename: 750883
Presenting Author: Kanani E. Titchen, MD
Department/Institution/Address: 1027 Arch Street, #205, Philadelphia, PA, 19107, United States
Phone: 302-932-2366
Fax:
Title: Human Sex Trafficking Education in Healthcare: Evidence for a Novel Free Online Curriculum
Kanani E. Titchen1, Suzanne L. Harrison2, Jessica DeLeon3 and Holly G. Atkinson4. 1Pediatrics, Thomas Jefferson University / Nemours - A.I. duPont Hospital for Children, Philadelphia, PA; 2Family Medicine, Florida
State University College of Medicine, Tallahassee, FL; 3Instructional Research & Graduate Programs, Florida State University College of Medicine, Tallahassee, FL and 4Dept of Medicine and Preventive Medicine,
Human Rights Program, Icahn School of Medicine at Mount Sinai, New York, NY.
BACKGROUND: In 2013, the Institute of Medicine recommended engaging "relevant sectors in developing, implementing, and evaluating training activities for professionals... who routinely interact with children and
adolescents on how to identify and assist victims and survivors" of sex trafficking. Additional calls have been made for evidence-based educational training about human trafficking among health providers.
OBJECTIVE: We developed an online video curriculum ("PATH") to provide education, screening tools, and resources about the domestic sex trafficking of minors. We hypothesized that physician trainees would (1)
increase their knowledge of warning signs, health issues, and screening practices, (2) desire additional training, and (3) recommend this curriculum to colleagues. We aim to prevent sex trafficking by facilitating
community and political advocacy and by enhancing the physician-patient relationship.
DESIGN/METHODS: Participants were 37 medical trainees (27% in med school and 73% in residency) who completed anonymous pre- and post-video surveys before and after viewing a video curriculum. The PATH
curriculum was developed by experts in the field of child maltreatment and human trafficking from multiple institutions and was co-produced with a film/video producer with experience in interactive motion-media
healthcare education.
RESULTS: Paired sample t-tests showed significant differences in those who plan to train as a first responder for victims of sex trafficking (t= 4.824; df =34 , p = .000); know the warning signs (t= -9.150; df = 34, p =
.000) and health issues (t=-8.919; df = 35, p=.000) related to sex trafficking; and know how to screen patients for sex trafficking (t=-13.663; df = 35, p = .000). Results also showed differences in the number of
participants who suspected that they had worked with a patient who was sex trafficked, but these were not significant (t=1.961; df = 36, p = .058). Most respondents (92.1%) “agreed” or “strongly agreed” they would
recommend the video to their colleagues, and 84.2% stated they plan to make changes in their practices to accommodate skills learned from the PATH module.
CONCLUSIONS: The PATH video curriculum is an effective tool for educating physicians-in-training about the sex trafficking of minors, including risk factors, screening techniques, and related health issues. Further
testing is needed among a broader physician audience to confirm the effectiveness of this educational module.
Filename: 750484
Presenting Author: Emmanuelle S. Topiol, MD
Department/Institution/Address: Pediatrics, 3601 A Street, Philadelphia, PA, 19134, United States
Phone: 14074843851
Fax:
Title: Evaluation and Optimization of Resident Perceptions in Screening for Postpartum Depression
Emmanuelle S. Topiol1, Shareen Kelly1, Bruce Bernstein1, Jodi Schaffer1 and Jeremiah Goldstein1. 1Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Postpartum Depression (PD) affects up to 12% of pregnant and post-partum females, with a higher prevalence in urban underserved and minority communities. It is well known that PD places
mother-baby dyads at risk for both acute and long-term harm ranging from developmental delay and poor healthcare utilization, to infanticide and suicide. For resident physicians, resources are often scarce to combat
these ills, as is the training to recognize these conditions.
OBJECTIVE: The purpose of this study is to evaluate the effectiveness of a pediatric resident curriculum around the issues of screening for and providing resources for families affected by PD. With a paucity of
literature focusing on resident education about PD, we aim to optimize awareness, screening, and subsequent interventions by residents. Our goal in this initial phase is to evaluate resident perception of and current
practices in evaluating for PD.
DESIGN/METHODS: Our approach explores resident-reported attitudes and behaviors concerning PD screening. Participants were trainees at St. Christopher's Hospital for Children. Educational material on PD, and
a newly established screening protocol including the validated Edinburgh Postpartum Depression Screen (EPDS), were implemented in the setting of an outpatient clinic lecture. A 10-question survey to evaluate
screening rates and perceived barriers was administered prior to this intervention, and after 3 months.
RESULTS: Surveys were completed by 28 residents pre-intervention and 30 post-intervention, with 15 of the latter having participated in both surveys. We found a statistically significant increase in the self-reported
frequency of screening by the residents at the 1, 2, and 4-month infant visits (59%vs.91%; 44%vs.81%, and 24%vs.71%, respectively), and in the use of the EPDS (14.2% vs. 80%). We also noted a decrease in the
reported number of barriers in screening, most notably in resident comfort level with screening.
CONCLUSIONS: We conclude that the implementation of an educational curriculum and formal screening protocol for PD is feasible in a pediatric resident clinic. Residents can readily improve awareness and
screening rates for PD and thus have a positive impact on their patients. Additional objective data tracking EPDS administration, documentation, and developing a multi-disciplinary team equipped to offer resources to
affected families will be evaluated in the ongoing study efforts.
Filename: 751561
Presenting Author: Matthew Kusulas, MD
Department/Institution/Address: Emergency Medicine, Nemours/AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, United States
Phone: 646-522-0093
Fax:
Title: The Effect of Team Care Plan Meetings on Resident Education in the Emergency Department
Matthew Kusulas1, Margarita Lorch1 and Arezoo Zomorrodi1. 1Emergency Medicine, Nemours/AI duPont Hospital for Children, Wilmington, DE.
BACKGROUND: Studies in the medical literature show that teamwork in the Emergency Department (ED) improves flow and patient safety. There is little data available regarding the effect of teams on resident
education.
OBJECTIVE: To evaluate the effect of Team Care Plan Meetings (TCPM) on resident education in the ED of a suburban pediatric hospital (PED) with a volume of approximately 50,000 visits per year.
DESIGN/METHODS: Traditionally, a care plan was made by clinicians and subsequently communicated to others on the treatment team. A multidisciplinary approach to developing the treatment plan was
implemented. This approach, known as TCPM, takes place at the bedside in the presence of trainees, supervising physicians, and ancillary staff.
Using a 5-point Likert scale, pediatric residents, PED attendings, and PED fellows ranked the communication between team members, resident autonomy, and quality of resident educational opportunities in the PED.
Attendings and fellows (supervisors) were surveyed both before and after the implementation of TCPM. Responses were analyzed using matched sample t-tests. Responses for residents who rotated before and those
who rotated after the implementation of TCPM were compared using independent sample t-tests.
RESULTS: Overall educational opportunities were perceived to improve by residents but not by supervisors (0.33, p=0.03 vs 0.16, p=0.52). The ability for supervisors to demonstrate physical exam skills was
perceived to improve by both supervisors and residents (0.96 vs 0.89, p<0.01). Opportunities for supervisors to demonstrate communication skills was perceived to improve by both supervisors and resident (0.81 vs
0.87, p<0.01). While residents perceived an improved ability to discuss pathophysiology, supervisors did not (0.49, p=0.01 vs -0.2, p=0.48). Residents perceived an improvement in opportunities to discuss differential
diagnosis, while supervisors perceived a decline (0.35, p=0.02 vs -0.52, p=0.02). Residents did not report a change in their ability to take time to think about the case and develop their own plan (0.09, p=0.55).
Team communications was perceived to improve by supervisors but not by residents (0.6, p=0.03 vs 0.18, p=0.23). Resident autonomy had no perceived difference by either supervisors or residents (-0.4, p=0.06 vs
-0.01, p=0.97).
CONCLUSIONS: TCPM improves the ability to demonstrate bedside skills without significantly hindering knowledge-based teaching, resident autonomy, or team communication.
Filename: 751410
Presenting Author: Tedbabe Degefie Hailegebriel, MD
Department/Institution/Address: 11215 Oak Leaf Dr, Apt 1820, Silver Spring, MD, 20901, United States
Phone: +1 202 765 6364
Fax:
Title: Bringing Care Closer To Home: A Cluster Randomized Trial of the Impact of Newborn Infection Management At Health Posts on Neonatal Mortality in Rural Ethiopia
Tedbabe Degefie Hailegebriel, Brian E. Mulligan, Simon Cousens, Berket Mathewos, Stephen Wall, Abeba Bekele, Jeanne Russlle, Deborah Sitrin, Biruk Tensou, Joy Lawn, Joseph de Graft Jhonson, Hailemariam
Legesse, Assaye Kassie, Sirak Hailu, Bogale Worku and Abdullah H. Baqui. 1Department of Health and Nutrition, Save the Children, Washington, DC; 2John Snow Research and Training Institute. Inc, Arlington, VA;
3
London School of Hygiene and Tropical Medicine, London, Greater London, United Kingdom and 4Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
BACKGROUND: To improve newborn survival by increasing coverage of treatment of neonatal infections, the Community Based Interventions for Newborns in Ethiopia (COMBINE) study evaluated a strategy of
providing treatment at the most peripheral level of the system, the health post, for families unable to access referral care.
OBJECTIVE: to evaluate a strategy to make treatment for neonatal infections available at health posts for families unable to access referral care, in order to increase coverage of life-saving treatment and improve
newborn survival.
DESIGN/METHODS: We performed a two-arm, community-based, cluster-randomized trial. In both study arms, the existing health system was strengthened at health posts and referral sites (health centers) and
instituted home visits during pregnancy and postnatal period. In addition, in the intervention arm, antibiotic treatment for newborn infections was made available at health posts when referral was not possible. The
primary study outcome was post day-1 neonatal mortality. Analysis was by intention to treat.
RESULTS: There was a large increase in the number of newborns with signs of severe infection presenting at health posts in the intervention arm. Among 576 newborns presenting with one or more signs of infection
at intervention health posts, 521 (90%) were recorded as treated at the health post and 41 (7%) as referred. Data were missing for 14 (2%) newborns. Of the cases treated at health posts, 414 (79%) were linked to
data on administered doses, of which 408 (99%) received 7 doses of gentamicin. Post day-1 neonatal mortality declined more in the intervention arm than the comparison arm between baseline and endline (13·8 to
11·2 per 1000 in the comparison arm; 18·2 to 9·4 per 1000 in the intervention arm). After taking baseline mortality rates and region into account, there was evidence for a reduction in mortality due to the intervention
(risk ratio 0·70; 95% CI 0·48 to 1·01; P=0·06).
CONCLUSIONS: When referral is not possible, antibiotic treatment of newborns at health posts is feasible and can contribute to reducing neonatal mortality.
Filename: 756330
Presenting Author: Sahel Hazrati, MPH
Department/Institution/Address: Inova Translational Medicine Institute, Claude Moore Building, 3300 Gallows Rd, Claude Moore Building, Falls Church, VA, 22042, United States
Phone: 703-939-5704
Fax: 703-776-7177
Is Presenting Author a Trainee? Yes, Ph.D. Student
Title: Congruence of Parental Genomic Variation By Country and Self-Report Race and Ethnicity in Ongoing Maternal Child Genomic Studies
Sahel Hazrati1, Kathi Huddleston1, Alma C. Fuller1, Wendy S. Wong1 and John E. Niederhuber1. 1InovaTranslational Medicine Institute, Falls Church, VA.
BACKGROUND: Concerns with minority representation in pediatric research is a challenge to adequately address the population and provide the appropriate “reference” gene set for analysis. The further development
of whole genome sequencing, as well as robust collection of clinical and demographic data, may assist to identify possible relationships between race and ethnicity and health care outcomes.
OBJECTIVE: To compare genetic, ancestral and self-report race/ethnicity data to electronic medical record (EMR), to determine the reliability and validity of available race/ethnicity data that is used to create pediatric
health care policies
DESIGN/METHODS: Two maternal child genomic studies at Inova Translational Medicine Institute have enrolled over 2,500 families.We have collected participants' biological specimens along with clinical data and
social/demographic factors. Data was collected over 3 years at Inova Fairfax Hospital, located in Northern Virginia, a highly diverse community. Racial and ethnic analysis was conducted and analyzed by principal
component analysis (PCA) to determine the participants' ancestral background along with investigating the congruence of the self-report race, ethnicity, and country of birth to hospital EMR.
RESULTS: EMR data on race and ethnicity are difficult to validate and are not a reliable source of documentation. Ancestral reference genetics does not correlate well to self-report race or ethnicity. Ancestral country
of birth provides improved reference genetics that may identify population variations
.
CONCLUSIONS: Race is a social construct that does not accurately identify ancestral genetic characterization. Race and ethnicity is an important component of pediatric health care outcomes research; yet is often
poorly constructed and documented. Future research may explore the use of ancestral reference genes to establish pediatric treatment protocols and develop pediatrics personalized medicine.
Filename: 752307
Presenting Author: Bushra Saleem, M.B.,B.S
Department/Institution/Address: Pediatrics, U. Maryland School of Medicine, 110 South Paca Street, 8th Floor, Baltimore, MD, 21201, United States
Phone: 4103286003
Fax:
Title: Intestinal Barrier Function in Preterm Infants: Relationship To Feeding and Antibiotic Exposure
Bushra Saleem1, Rose M. Viscardi1, Alessio Fasano3, Laurence S. Magder2, Jonathan B. Meddings4, Shiv Kapoor1 and Adora Okogbule-Wonodi1. 1Pediatrics, U. Maryland School of Medicine, Baltimore, MD;
2
Epidemiology & Public Health, U. Maryland School of Medicine, Baltimore, MD; 3Pediatrics, Massachusetts General Hospital for Children, Boston, MA and 4Cummin School of Medicine, U. Calgary, Calgary, AB,
Canada.
BACKGROUND: Intestinal permeability (IP) is higher in preterm infants and "leaky gut" is a risk factor for NEC, but factors that modulate intestinal barrier maturation are unknown. We hypothesize that changes in IP
measured by the urinary excretion of nonmetabolized sugar probes lactulose (intestinal paracellular pathway marker)/rhamnose (transcellular pathway) (La/Rh) in preterm infants during the first 2 wk of life will be
affected by feeding and antibiotic exposures.
OBJECTIVE: To evaluate the effects of feeding and antibiotic exposure on IP by measuring urine La/Rh ratios in preterm infants 240-326 wk GA during the first 2 wk of life.
DESIGN/METHODS: 27 infants 240-326wk GA <4d of age enrolled 04/2012 to 03/2014 received 1 ml/kg La/Rh (8.6 g La+140 mg Rh/100 mL) enterally on study days 1, 8 and 15 and urine collected for 4h. La/Rh were
measured by HPLC. Demographic, feeding and perinatal antibiotic exposure data were recorded. Increased IP was defined as La/Rh ratio ›0.05.
RESULTS: Of 27 subjects, 16 (59%) were male and 12 (44%) African-American with GA 29.7±2.5 wk and BW 1,338±410 g. As shown in the figure, IP was elevated on study d1, decreased over 2 wk, but remained
higher in infants ≤28 wk GA compared to IP in infants >28 wk GA (*p=0.015, study d8).
Compared to vaginal delivery, C/S was associated with higher d1 La/Rh ratio (0.24±0.15, mean±SD vs. 0.14±0.08; p=0.037). The La/Rh ratio decreased between d1 and d8 in 24/25 (96%) subjects, but increased
between d8 and d15 in 6/24 (25%) subjects. Compared to formula-fed infants, exclusively breastmilk-fed infants were less likely to experience an increase in IP between d8 and d15 (2/18, 11%; vs 4/6, 67%; p=0.018).
In contrast, cefotaxime Rx was associated with increased IP between d8 and d15 (3/4, 75% vs 3/20, 15%; p=0.035).
CONCLUSIONS: GA and postnatal age-dependent intestinal barrier maturation in preterm infants may be altered by feeding and antibiotic exposures. Funded by NCCAM R34AT006945.
Filename: 753898
Presenting Author: Colleen A. Nugent, M.D., M.S
Department/Institution/Address: Digestive Diseases and Nutrition, Women & Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, 14222, United States
Phone: 17168787793
Fax: 17168883842
Title: The Relationship Between Psychological Distress and the Severity of Inflammatory Bowel Disease in Adolescents
Colleen A. Nugent1, Peter S. Martin2, Chang-Xing Ma3, Robert D. Baker1 and Susan S. Baker1. 1Department of Pediatrics, Division of Digestive Diseases and Nutrition, Women & Children's Hospital of Buffalo, SUNY
Buffalo, Buffalo, NY; 2Department of Psychiatry, Division of Community Psychiatry, Erie County Medical Center, Buffalo, NY and 3Department of Biostatistics, State University at Buffalo, Buffalo, NY.
BACKGROUND: Inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), is a chronic disease associated with abdominal pain, bloody diarrhea and weight loss. Adolescents
with IBD struggle with a psychosocial burden that can manifest as externalizing symptoms (such as somatic complaints, aggressive actions) and internalizing symptoms (such as depression and anxiety).
Cross-sectional studies have shown that anxiety and depression are the most common co-occurring psychiatric conditions in patients with IBD. Validated tools exist to assess psychological distress.
OBJECTIVE: The purpose of our study was to examine the relationship between IBD severity and psychological distress in adolescent patients. The concordance between patients' and parents' perception of
psychological distress was assessed. A secondary outcome proposed was to utilize a screening measure that could be incorporated into a clinic workflow without excessive burden to either patients or staff.
DESIGN/METHODS: A retrospective IRB approved chart review of 120 adolescents diagnosed with IBD was performed. Parents completed the Pediatric Symptom Checklist (PSC) and adolescents were provided the
Youth Pediatric Symptom Checklist (YPSC) in one of three settings: inpatient, outpatient, or an infusion clinic. To measure IBD severity, the score on the Pediatric Crohn's Disease Activity Index (PCDAI) or the
Pediatric Ulcerative Colitis Activity Index (PUCAI) was recorded.
RESULTS: Our results showed that disease severity and psychological distress correlate. Parent and youth reports of distress correlated on overall scores and for specific parameters, primarily internalizing symptoms
of depression and anxiety. There was a large number of potential referrals triggered per total score on both the PSC and YPSC.
CONCLUSIONS: The screening tool offers insight into the psychological state of the adolescent and how a parent perceives it. The use of the PSC/YPSC is easily administered and integrated into clinical practice
work flow. This screening model could easily be adopted by other subspecialties to improve the mental health of children with chronic illness.
Filename: 750799
Presenting Author: Anthony G. Pompa
Department/Institution/Address: University of Pittsburgh School of Medicine, M240 Scaife Hall, 3550 Terrace St, Pittsburgh, PA, 15261, United States
Phone: 412-335-9871
Fax:
Title: Intestinal Expression of microRNA-17 Is Significantly Increased in Human Neonates with Surgical Necrotizing Enterocolitis
Anthony G. Pompa1, Jacqueline Ho1, Jay K. Kolls1 and Misty Good1. 1University of Pittsburgh School of Medicine, Pittsburgh, PA.
BACKGROUND: Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal death in preterm infants. A challenge in NEC research is the ability to determine which babies are at risk for NEC development.
While regulation of inflammatory gene expression within the intestine is not well understood, recent studies demonstrate that small noncoding RNAs called microRNAs (miRNAs) can regulate intestinal barrier function
and the inflammatory immune response. The microRNA 17~92 cluster, which includes microRNAs 17, 18a, 19b, and 20a, has been linked with diseases involving intestinal inflammation, including inflammatory bowel
disease, however the association between microRNAs and NEC remains unexplored.
OBJECTIVE: We hypothesize that microRNAs, specifically those in the miRNA-17~92 cluster, are differentially expressed in the intestine of premature infants with NEC and that certain miRNAs play a critical role in
the regulation of the intestinal barrier dysfunction seen in NEC.
DESIGN/METHODS: This study was performed after approval by the University of Pittsburgh Institutional Review Board protocol number PRO09110437. Intestinal samples were obtained from human neonates
undergoing intestinal resection for NEC or at the time of stoma closure (“healed NEC”). RNA was isolated from these samples using TRIzol® Reagent (Ambion®). A total of 10ng/µl RNA was reverse transcribed to
cDNA using TaqMan MicroRNA Assays (Applied Biosystems) with RT primers specific for the miRNA of interest, and qPCR amplification reactions were run on a C1000 Touch Thermal Cycler System (BioRad, Inc.).
RESULTS: Intestinal samples from infants with NEC demonstrated a statistically significant increase (p=0.0017) in expression of microRNA-17, versus intestine resected at the time of stoma closure. The other
microRNAs in the 17~92 cluster, did not show a statistically significant difference in NEC versus the healed NEC tissue.
CONCLUSIONS: Intestinal expression of microRNA-17 was significantly increased in infants with surgical NEC. The identification of novel biomarkers, such as miRNA expression, may raise the possibility for novel
diagnostic and therapeutic approaches of this devastating disease by further exploring microRNA expression in other biological samples from affected infants.
Filename: 751088
Presenting Author: Eric M. Ly, MD
Department/Institution/Address: Pediatrics, University of Maryland School of Medicine, 110 S. Paca St., 8th Floor, Baltimore, MD, 21201, United States
Phone: 410-328-6003
Fax: 410-328-1076
Title: Choline Reduces Bilirubin Inhibition of L1 Cell Adhesion Molecule (L1) Mediated Neurite Outgrowth
Eric M. Ly1, Gail Cameron1, Ningfeng Tang1, Min He1 and Cynthia F. Bearer1. 1Pediatrics, University of Maryland School of Medicine, Baltimore, MD.
BACKGROUND: Neonatal hyperbilirubinemia causes developmental disability, but its mechanism is unknown. Bilirubin binds to phospholipids in cell membranes. These phospholipids exist in either liquid-ordered
domains (lipid rafts), or liquid-disordered domains. L1 cell adhesion molecule (L1), a protein critical to development of the central nervous system, depends on lipid rafts to promote neurite outgrowth (NOG). Lipid raft
disruption inhibits L1-mediated NOG. Our preliminary work has shown that bilirubin inhibits L1-mediated NOG. Choline, a precursor to phospholipids in lipid rafts, has been shown to ameliorate the inhibition of
L1-mediated NOG by other neurotoxicants. Our hypothesis is that choline is protective against bilirubin inhibition of L1-mediated NOG.
OBJECTIVE: To determine if choline reduces bilirubin inhibition of L1-mediated NOG using cerebellar granule neurons (CGN).
DESIGN/METHODS: CGN from 6 day old rat pups were plated on poly-L-lysine (PLL). To some cultures, 20, 40 or 80 µM of choline was added. After 24 h, a clinically relevant concentration of bilirubin (5 µM, 1:14
bovine serum albumin) was added to the media. A soluble form of L1 was added to the media of some cultures. Cultures were incubated for 24 h, then fixed and immunostained for tubulin III to visualize neurites.
Neurite length was measured by a masked investigator using computer assisted software (ImageJ) using an a priori design. For each experiment, the mean of the length of all neurites was calculated. The mean +/SD were then calculated across experiments. Significance was determined by 2-tailed paired t-test.
RESULTS: L1 significantly increased neurite length of CGN from that grown on PLL alone. Bilirubin significantly reduced neurite length of CGN treated with L1. Media supplementation with choline reduced the
inhibitory effect of bilirubin and was most effective at 40 ɥM.
CONCLUSIONS: Choline may ameliorate bilirubin neurotoxicity. Supplementation may be considered in premature infants.
Filename: 753651
Presenting Author: Srujana Rallabandi, MBBS, MPH
Department/Institution/Address: Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 651, Rochester, NY, 14642, United States
Phone: 15852751847
Fax:
Title: Unconjugated Hyperbilirubinemia and Retinopathy of Prematurity in Premature Infants
Srujana Rallabandi1, Hongyue Wang2 and Sanjiv B. Amin1. 1Pediatrics, University of Rochester Medical Center, Rochester, NY and 2Biostatistics, University of Rochester Medical Center, Rochester, NY.
BACKGROUND: Retinopathy of prematurity (ROP) is caused by oxidative stress. Improving the anti-oxidant status may decrease the incidence and severity of ROP. Unconjugated bilirubin is a naturally occurring
antioxidant; however, its association with ROP has not been well studied.
OBJECTIVE: To determine if degree of jaundice is associated with the incidence and severity of ROP in <31 weeks gestational age (GA) infants.
DESIGN/METHODS: A prospective observational study was performed to include 24-31 weeks GA infants admitted to the NICU within 12 hours after birth. Infants with chromosomal disorders, congenital
malformations, & TORCH infection were excluded. Total serum bilirubin (TSB) was measured daily during the first postnatal week and thereafter as clinically indicated. All infants were evaluated for ROP and graded
for severity using International ROP Classification. Infants were categorized into 4 groups based on the worst finding in either eye: infants with no ROP; mild ROP (stage 1 in zone 2 or 3); moderate ROP (stage 2 in
zone 2 or 3); & severe ROP (≥ stage 3 in any zone or any stage in zone 1).
RESULTS: Of 347 infants studied, 108 developed ROP. There was a difference in GA, respiratory distress syndrome (RDS), days on oxygen, sepsis, # of erythrocyte transfusions, postnatal steroids, peak TSB, &
days on TPN between infants with and without ROP. Controlling for identified confounders, peak TSB was marginally associated with the incidence of ROP [OR 0.80,95% CI:0.68-1.02]. There was a difference in GA,
clinical sepsis, patent ductus arteriosus (PDA), # of erythrocyte transfusions, days on TPN, days on oxygen, postnatal steroids, & peak TSB, but not in gender, race, asphyxia, antenatal steroids, chorioamnionitis, &
RDS between the 4 grps (Table). In an ordered regression analysis, controlling for confounders, peak TSB was marginally associated with severity of ROP [coefficient -0.21, 95% CI:-0.44 to 0.009, p=0.06].
No ROP (n=239) Mild ROP (n=54) Moderate ROP (n=33) Severe ROP (n=21) P
GA(wks)
28.2±1.7
26.9±1.6
26.5±1.7
25.1±1
0.01
Clinical Sepsis(%)
41
54
73
86
0.01
PDA(%)
35
28
48
67
0.01
Erythrocyte Transfusions(#)
2.4±3.1
4.7±4.3
7.2±4.7
10.3±5.7
0.01
Days on TPN
27±24
35±26
48±34
49±16
0.01
Days on Oxygen
28±28
43±41
54±32
82±29
0.01
Postnatal Steroids(%)
9
7
21
68
0.01
8.1±1.4
8±1.1
7.4±0.9
0.01
Peak Total Serum Bilirubin(mg/dL) 9±1.6
CONCLUSIONS: Neonatal jaundice through its antioxidant effect may be protective for ROP in premature infants.
Filename: 753057
Presenting Author: Sean M. Bailey, MD
Department/Institution/Address: 25 Cedar Dr., Roslyn, NY, 11576, United States
Phone: 212-263-0201
Fax:
Title: A Prospective Observational Pilot Study Analyzing Variation in Irradiance Administered During Phototherapy
Sean M. Bailey1, Karen Yan1, Rebecca Zarchin1, Martha Caprio1 and Pradeep V. Mally1. 1Pediatrics, New York University School of Medicine, New York.
BACKGROUND: Phototherapy is standard treatment for unconjugated hyperbilirubinemia. With around 4 million U.S. births annually, hundreds of thousands of term and preterm infants are likely treated each year.
Most often, phototherapy is administered with overhead lamps that emit light in the blue/green spectrum (400-500nm) so that photo conversion of unconjugated bilirubin to lumirubin occurs. The rate of this process
depends on the optimal spectrum of light exposure, and the dispersed irradiance of that light on the exposed skin surface. A variety of phototherapy lamps are currently used with no specific standardization.
OBJECTIVE: As dosages of phototherapy irradiance are recommended, the primary purpose of this study was to determine the variability in irradiance that infants undergoing phototherapy are exposed to.
DESIGN/METHODS: IRB approved prospective observational study in the nurseries and NICUs of NYULMC and Bellevue Hospital. A newly calibrated light meter (Olympic Bilimeter,Natus,San Carlos,CA) was used
to measure mean irradiance levels on each subject (from 5 sites,head to foot) undergoing overhead phototherapy, as well as measurements at a biliblanket level if used. Measurements occurred twice daily while on
treatment.
RESULTS: 70 subjects were included, comprised of 33 preterm, 13 late preterm, and 24 term infants. 268 individual sets of measurements taken. Overall, the mean irradiance level achieved was 14.5±7.7
µW/cm2/nm, with a range of 35.5 µW/cm2/nm. Spotlight overhead lamps achieved the highest mean irradiance levels, 21.6±7.0 µW/cm2/nm, while LED overhead lights achieved the lowest 9.4±2.9 µW/cm2/nm
(p<0.001). There was poor correlation between conventionally used nomenclature “single”, “double”, and “triple” phototherapy and actual devices used or irradiance levels that were administered. In total, 24% of
irradiance measurements obtained fell below 9 µW/cm2/nm, the mean minimum intensity level recommended by the American Academy of Pediatrics needed to achieve standard phototherapy.
CONCLUSIONS: There is a wide degree of variability in irradiance received by infants undergoing phototherapy. Developing specific institutional guidelines, encouraging medical staff to frequently check irradiance
levels, and utilizing specific orders in place of traditionally used phototherapy nomenclature may result in the delivery of more consistently appropriate levels of irradiance to infants and improved patient care.
Filename: 753577
Presenting Author: Carole Samango-Sprouse
Department/Institution/Address: 2772 Rutland Rd, Davidsonville, MD, United States
Phone: 4432237323
Fax:
Title: “Hiding in Plain Sight”: Common Neurodevelopmental Disturbances in Undiagnosed Children with X and Y Chromosomal Variations
Carole Samango-Sprouse1,2,3, D. Corley Gibbs2, Teresa Sadeghin2,3, Diana P. Sisson2 and Andrea L. Gropman1,4. 1Pediatrics, George Washington University School of Medicine, Washington, DC; 2The Focus
Foundation, Davidsonville; 3Neurodevelopmental Diagnostic Center, Davidonsville and 4Neurodevelopmental Disabilities and Neurogenetics, Children's National Medical Center, Washington, DC.
BACKGROUND: While X and Y chromosomal variations occur in up to 1 in 400 live births, only 10-25% of cases are diagnosed. Recent publications have demonstrated the value of early detection and treatment in
minimizing the developmental disturbances associated with these disorders.
OBJECTIVE: This study reviews the phenotypic presentation of the most common disorders; XXY, XYY, and XXX, from infancy through adolescence in order delineate these disorders from the comorbid
neurodevelopmental disturbances that may “hide” these children's cytogenetic profiles.
DESIGN/METHODS: Using standardized neurodevelopmental tests and behavioral questionnaires, the phenotypic profiles of more than 100 children with these disorders were characterized.
RESULTS: The majority of children in all three groups had normal intellectual development (IQ > 90, Wechsler scales) throughout childhood, however verbal IQ was lower than performance IQ in all three groups.
Language based learning disorders (LLD) occurred in more than 90% of the children with reading disorders and written language disorders. Expressive language was considerably higher than receptive language in
30% of children with XXX and XXY, but similar discrepancies were observed in less than 10% of children with XYY. Neurobehavioral problems were more common in boys, particularly anxiety (> 30% in XXY and
XYY) and ADHD (27% of XYY; 23% of XXY). Rule breaking behavior was most commonly observed in boys with XYY (26%) compared to less than 10% of children with XXY or XXX. The most common psychosocial
behavior problem observed in girls with XXX was anxiety (18%). Over 25% of children in all three groups had generalized social problems or atypical social behaviors indicated by the CBCL.
CONCLUSIONS: As a result of these characteristics, children may be diagnosed with ASD, ADHD, LLD, or anxiety without investigating the possible chromosomal etiology. The importance of early diagnosis of these
common disorders will be discussed including positive impact of early androgen treatment for boys with 47, XXY, and therapeutic intervention for children with XYY and XXX that can ameliorate symptoms of these
disorders. In light of the ACMG's most recent guidelines for genetic testing, pediatricians should consider a chromosomal microarray test for patients presenting with these common neurodevelopmental disturbances,
as there may be an underlying chromosomal etiology.
Filename: 750260
Presenting Author: Michele Alexandra L. Ledesma, MD
Department/Institution/Address: Pediatrics, St. Barnabas Hospital, 4422 Third Ave., Bronx, NY, 10457, United States
Phone: 718-960-6635
Fax: 718-960-9418
Title: Relationship Between Child Sleep Patterns, Inattention and Hyperactivity
Michele Alexandra L. Ledesma1, Daniel Erichsen1, David H. Rubin1,2 and Paulo R. Pina1,2. 1Pediatrics, St. Barnabas Hospital, Bronx, NY and 2Pediatrics, Albert Einstein College of Medicine, Bronx, NY.
BACKGROUND: The relationship between child sleep, and attention and activity, has long been recognized, but not adequately studied. Sleep problems have been demonstrated to be a co-morbidity of attention
deficit/hyperactivity disorder (ADHD); conversely, attentional deficits and hyperactive behavior are frequently reported in children with obstructive sleep apnea or sleep-disordered breathing. Sleep phenotypes have
been proposed for ADHD which include increased sleep latency, decreased sleep time, and frequent awakenings. However, there are few studies that examine the polysomnographic relationship between sleep
patterns and symptoms of inattention and hyperactivity.
OBJECTIVE: To examine the relationship between sleep patterns, inattention and hyperactivity in pediatric patients.
DESIGN/METHODS: Retrospective chart review of pediatric patients referred for sleep studies (polysomnography) from January 2012 to August 2014 at an urban university-affiliated community hospital Sleep
Medicine Center. Inclusion criteria: patients 5-18 years whose parents answered the abbreviated Conners' parent-teacher questionnaire. Data collected included total sleep time, sleep onset latency, sleep efficiency,
time spent in stages 1-3 and REM sleep, awakenings, cortical arousals, and periodic limb movements; respiratory data included apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen
saturation. Conners' results were scored from 0 to 30.
RESULTS: 95 patients had complete sleep study data and a completed Conners' questionnaire. Using linear regression, there was a significant association between inattention and hyperactivity as measured by the
Conners' score and sleep latency (p=0.03), sleep efficiency (p=0.038), and percent of sleep time spent in REM (p=0.035), even when adjusted for age and BMI. There was no significant association between Conners'
score and sleep time, awakenings, arousals, AHI, RDI, oxygen saturation, and periodic limb movements.
CONCLUSIONS: These data suggest that there is a significant relationship between sleep quality and symptoms of inattention and hyperactivity. Patients with higher Conners' scores were more likely to have delayed
sleep onset, but also have better sleep efficiency and increased REM sleep. Further research is needed to investigate whether sleep study findings will be useful clinically to identify children at risk for ADHD.
Filename: 752810
Presenting Author: Ellen C. Perrin, MD
Department/Institution/Address: Developmental-Behavioral Pediatrics, Tufts Medical Center, 800 Washington St., Boston, MA, 02111, United States
Phone: 617-636-0648
Fax:
Title: Comparison of Screening Strategies To Detect the Full Range of Developmental-Behavioral Problems Among Young Children
Daryl W. Garfinkel1, Ana F. El-Behadli1, Radley C. Sheldrick1 and Ellen C. Perrin1. 1Developmental-Behavioral Pediatrics, Tufts Medical Center, Boston, MA.
BACKGROUND: The connection between behavioral symptoms and neurodevelopmental trajectories is increasingly recognized. Although behavioral and developmental problems both benefit from early intervention
and are of interest in primary care, little is known about their co-occurrence or how well they are detected by screening.
OBJECTIVE: To examine the co-occurrence of developmental and behavioral problems among young children and the sensitivity of developmental screeners versus comprehensive screening strategies to detect
these problems.
DESIGN/METHODS: In an ongoing NICHD-funded study, parents of 320 children (9-66 months) were recruited at a large pediatric practice. Parents completed a packet of developmental and behavioral screening
questionnaires about their children, including the Ages & Stages Questionnaire, 3rd edition, Ages & Stages-Social/Emotional, Parents' Evaluation of Developmental Status, and Survey of Wellbeing of Young Children.
Based on these results, families were selected for a clinical assessment involving developmental testing and structured diagnostic interviews.
RESULTS: Of the 137 children whose screening results were positive, 31% scored positive on only behavioral screeners, 38% on only developmental screeners, and 31% on both (see Fig. 1a). Of the 46 children
identified in the subsequent clinical assessments as having problems that require further services, 51% had only developmental problems, 36% had only behavioral problems, and 13% had both (see Fig. 1b). Use of
developmental screeners alone was not sensitive to the full range of problems identified (sensitivity = 36-60%). Comprehensive strategies that also included behavioral screeners displayed increased sensitivity,
outperforming developmental screeners by approximately 15-17% (p<.02).
CONCLUSIONS: These results suggest that comprehensive screening systems assist in the detection of the full range of developmental-behavioral problems among young children.
Filename: 752811
Presenting Author: Radley C. Sheldrick, PhD
Department/Institution/Address: Developmental-Behavioral Pediatrics, Tufts Medical Center, 800 Washington St., Boston, MA, 02111, United States
Phone: 617-636-4864
Fax:
Title: Heterogeneity among Children Presenting with Developmental Problems
Brenda Rojas1, Laura Ramirez1, Susan E. Marakovitz1, Radley C. Sheldrick1 and Ellen C. Perrin1. 1Developmental-Behavioral Pediatrics, Tufts Medical Center, Boston, MA.
BACKGROUND: The American Academy of Pediatrics encourages pediatricians to conduct developmental screening. Previous research has examined the sensitivity of developmental screeners to delays as
assessed by “gold standard” tests. Few studies have examined how differences in presentation of developmental problems influence screening sensitivity.
OBJECTIVE: To describe the heterogeneity of developmental problems among young children and explore its effect on the sensitivity of screening instruments.
DESIGN/METHODS: In an ongoing NICHD-funded study, parents of 320 children (9-66 months) were recruited at a large pediatric practice. Parents completed a packet of behavioral and developmental screening
questionnaires including the Ages and Stages Questionnaire-3 (ASQ-3), the Parents' Evaluation of Developmental Status (PEDS), and the Survey of Wellbeing of Young Children (SWYC). Using these data, 72
children were selected for a clinical assessment including the Bayley Scales of Infant Development (BSID-III) and the Differential Ability Scales (DAS-II).
RESULTS: Of the 72 children assessed, 36 were identified as having a developmental problem: 29 had developmental delays in cognition, communication, and/or motor domains; an additional 7 had articulation
problems or a significant difference between verbal and nonverbal subtests of the DAS (p<.01), indicating a risk for learning problems.
Developmental screening instruments were more sensitive to delays in cognition, communication and/or motor development (sensitivity = 38-63%) than they were to articulation problems and uneven verbal and
nonverbal skill development (sensitivity = 14-40%).
CONCLUSIONS: Our preliminary data suggest that screening instruments may not be sensitive to all types of developmental problems among young children. Pediatricians should be alert to developmental problems
that screening instruments are unlikely to detect.
Filename: 754269
Presenting Author: Naixue Cui
Department/Institution/Address: 316 S 40th ST, APT 3, Philadelphia, PA, 19104, United States
Phone: +1 215 290 6087
Fax:
Is Presenting Author a Trainee? Yes, Ph.D. Student
Title: The Effect of Low Blood Lead Concentrations on Working Memory in Chinese Children
Naixue Cui1 and Jianghong Liu1. 1School of Nursing, University of Pennsylvania, Philadelphia, PA.
BACKGROUND: Lead exposure has been associated with decreased IQ and impaired neurocognitive and motor functions in childhood. Most studies as far have been focused on high lead exposure; few studies have
investigated low lead exposure with specific components of neurological function, such as working memory. Working memory is an important domain of human cognition required for learning and optimal school
performance.
OBJECTIVE: The present study aims to examine the effect of low lead exposure on working memory in preadolescence using a large, community based, longitudinal cohort sample of Chinese children.
DESIGN/METHODS: The present study is a cross-sectional part of an ongoing longitudinal cohort project, the China Jintan Child Cohort Study. Eight hundred and fifteen (54% boys, 46% girls) children with a mean
age 12 years (SD=0.39) were recruited in 2011-2013. Blood specimens were collected for each child and blood lead concentrations were assessed using graphite furnace atomic absorption spectrophotometer per
protocol. Their working memory ability was assessed using computerized four subtests (i.e. Dot Memory, Number Memory, Dot Trajectory and Box Transform Memory) of the Working Memory Measurement Software.
RESULTS: All children's blood lead concentrations were ≤ 9.2 ug/dl with a mean 3.16ug/dl (SD=1.17) and a median of 2.90ug/dl respectively. One principal component of working memory was derived from Principal
Component Analysis which had an eigenvalue of 1.79 and 44.87% of the variance. Compared with those with blood lead levels lower than the median (2.90 ug/dl, children with higher than median (2.90 ug/dl ) had
poorer working memory (β = -0.25, robust s.e.=0.04, p<0.001) after adjusting children's sex and age.
CONCLUSIONS: Findings suggest that very low blood lead concentrations in childhood, even as low as 2.90 to 9.20 ug/dl, have adverse impact on working memory among Chinese children. The present study
provides important pediatric clinical implications that early detection and intervention of lead exposure in childhood are warranted to prevent cognitive impairment.
Filename: 754501
Presenting Author: Natalie Colaneri, BA
Department/Institution/Address: Developmental-Behavioral Pediatrics, Cohen Children's Medical Center of NY, 1983 Marcus Ave, Suite 130, Lake Sucess, NY, 11042, United States
Phone: 516-205-4807
Fax:
Is Presenting Author a Trainee? Yes, Other - Recent College Graduate
Title: Physicians' Knowledge About the Legal Consequences of Stimulant Diversion: Perception vs. Reality
Natalie Colaneri1, Sujit Vettam2, Majnu John3 and Andrew Adesman1. 1Developmental-Behavioral Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY; 2Vettam Data Solutions, Baltimore, MD and
3
Center for Psychiatric Neuroscience, Feinstein Institute of Medical Research, NSLIJ, Manhasset, NY.
BACKGROUND: There are growing concerns about ADHD teens misusing or diverting their stimulant medication (SM). Physicians (MDs) who prescribe SM to youth with ADHD should be qualified to educate their
patients about the legal consequences (LC) of diversion and misuse (D/M) of SM.
OBJECTIVE: To assess and compare actual and reported MD knowledge about LC of D/M of SM and determine if it is related to MD SM prescription volume
DESIGN/METHODS: A questionnaire focused on D/M was mailed to 3child neurologists (CN), child psychiatrists (CP), and developmental-behavioral pediatricians (DBP) in the US. Only responses by MDs who
currently prescribe SM were included in the analysis. MDs rated on a 3-point Likert scale how qualified they feel to educate their ADHD patients about the LC of D/M of SM. MD knowledge was assessed with the legal
question (LQ) “To your knowledge, if patients with ADHD give their SM to a friend, does it carry the same LC as them selling their SM to a stranger?”; response choices were “Yes” (correct), “No” (incorrect), and “Not
Sure”.
RESULTS: 832 valid responses were received: CN=106, CP=579, DBP=141. MDs were also classified based on how many high school students with ADHD they currently treat with SM?”: low prescribers (LP) = 1-10
patients [n=159], medium prescribers (MP) = 11-30 [n=249], and high prescribers (HP) >30 [n=424]. Approximately half of all MDs said they were adequately qualified to educate about LC of D/M of SM, yet 32% of
these MDs couldn't correctly answer the LQ. Figure 1 shows the % of MDs answering LC correctly relative to self-assessment of their knowledge. Figure 2 shows the association between self-assessment and
knowledge for the different subspecialties and based on patient volume.
CONCLUSIONS: Many specialists in all 3 disciplines – CN, CP, and DBP -- did not feel qualilified to counsel teens with ADHD about LC of D/M of SM; many who felt qualified incorrectly answered an important LQ.
MDs need to be educated about LC of D/M so that they can accurately counsel their patients.
Filename: 753856
Presenting Author: Joseph R. Isler, PhD
Department/Institution/Address: Pediatrics, Columbia University, 622 W 168 St P&S 9-401, New York, NY, 10032, United States
Phone: 1-212-342-4151
Fax:
Title: Oxygen Saturation Profiles in Extremely Low Birth Weight (ELBW) Infants with and without Supplemental Oxygen
Joseph R. Isler1, Philip G. Grieve1, Marilyn Weindler1, David A. Bateman1, Marianne Garland1, Raymond I. Stark1 and Rakesh Sahni1. 1Department of Pediatrics, Columbia University, New York, NY.
BACKGROUND: Current clinical practice for ELBW infants receiving supplemental O2(SO) involves close monitoring of hemoglobin O2saturation (SpO2) with pulse oximetry and making necessary adjustments in
FiO2to target an SpO2range of 90-95%. Despite challenges encountered in achieving the target and concerns for associated morbidities, the use of SOis largely unquantified.
OBJECTIVE: To evaluate and compare SpO2profiles in ELBW infants with and without SO usage during neonatal care.
DESIGN/METHODS: Using BedMaster, a system that interfaces with bedside monitors to continuously collect and archive vital signs, waveforms, and alarm data, we analyzed SpO2from pulse oximetry and SO
treatment from FiO2for the entire NICU hospitalization (12.6±6.8 wks) of 39 ELBW infants (22 male; birth weight 838±121 g; GA 26±1.9 wks). SpO2 data were first subjected to a novel artifact reduction algorithm: EKG
heart rate (HR) was compared with oximeter pulse rate (PR) and SpO2measurements were considered valid only if the difference between simultaneous HR and PR was ≤1 SD from the 1h smoothed HR. SpO2data
were then divided into periods with and without SO and percentage of time spent in ranges <85%, 85-89%, 90-95% and >95% was computed. Data were then pooled across infants and compared for percentage of
time within each range with and without SO using t-tests.
RESULTS: Percentage of time in SpO2ranges <85%, 85-89%, 90-95% and >95% was 12%, 11%, 40%, 31% with SO and 8%, 7%, 27%, 54% without SO (p<0.0001 for differences in all SpO2ranges).There was no
difference in artifact time.
CONCLUSIONS: Maintaining SpO2in a targeted range is challenging both with and without SO in ELBW infants. They spend a high proportion of time in a broad range of saturations from hypoxemia to hyperoxia
following current guidelines. Establishment of clinical protocols to reduce the incidence of hypo- and hyperoxia can be aided with the use of continuously recorded monitor data.
Filename: 753993
Presenting Author: Natalia A. Isaza, MD
Department/Institution/Address: 3504 Dundee Driveway, chevy Chase, MD, 20815, United States
Phone: 202-256-3462
Fax:
Title: Newborn's Brain and Somatic Tissue Oxygenation During Skin-to-Skin Contact in the NICU
Natalia A. Isaza1, Khodayar Rais-Bahrami1, Mariam Said1 and Mauricio Cabrera2. 1NICU, Children´s National Medical Center, Washington, DC and 2Industrial Engineering Department, University of Puerto Rico at
Mayagüez, Mayagüez, PR.
BACKGROUND: Skin-to-skin (S2S) can improve care of LBW newborn, including positive physiologic effects, parental-infant bonding & breastfeeding. No conclusive evidence of cerebral & somatic oxygenation during
S2S contact in preterm and term newborns is available.
OBJECTIVE: Determine newborn's physiologic vital signs, cerebral, mesenteric oxygenation detected by NIRS monitoring during S2S & elucidate response of cerebral & somatic oxygenation in hemodynamically
stable NICU patients during S2S.
DESIGN/METHODS: Prospectic study. Data from 26 infants with 0.54-3.7 kg BW, age 3-109 days, GA 23-41 weeks, weight 1.5-4.8 Kg. Patients acutely ill excluded. Vital signs including SO2 & cerebral/somatic
oxygenation recorded 1 hr before, at least 1 hr during S2S, and 1 hr after. Two NIRS probes placed at forehead & abdomen. SctO2 mean & variability determined for each phase & compared to detect changes in
SctO2 value & variability.
RESULTS: Changes determined by averaging subject data per phase to detect significant changes using two-tailed paired data T-test between phases where significance p<0.05. Number of desaturation, bradycardia,
apneas decreased during S2S. [Figure 1]. Compare changes after S2S to before: 61% decrease in SctO2; overall mean SctO2 decreased slightly (0.6%, p=0.37 and 0.5%, p=0.44)
All subjects
StO2 Mean (SD)
StO2 Variability* (SD)
Before (Crib)
74.1 (5.3)
3.04 (1.17)
During
73.3 (5.3)
3.30 (1.46)
After (Crib)
73.2 (5.9)
3.08 (1.78)
; no statistically significant changes on vital signs.
CONCLUSIONS: Cerebral and mesenteric StO2 were stable during, & after S2S. S2S contact/breastfeeding can have positive impact on mesenteric oxygenation to help feeding tolerance in patients at risk of NEC.
Cerebral metabolism changes due to touch stimulus and/or hemodynamic changes by repositioning baby may affect positively cerebral SctO2. Future directives include correlation of mode & timing of feeds with S2S
& somatic oxygenation.
Filename: 753660
Presenting Author: Kelley Z. Kovatis, MD
Department/Institution/Address: Department of Neonatology, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, Pennsylvania, 19104, United States
Phone: 6106392228
Fax:
Title: Effect of Caffeine on Intermittent Hypoxia in Preterm Infants
Kelley Z. Kovatis1, Juliann M. Di Fiore2, Richard J. Martin2 and Haresh Kirpalani1. 1Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA and 2Neonatology, Rainbow Babies, Cleveland, OH.
BACKGROUND: Apnea is associated with multisystem morbidity and mortality and is often treated with caffeine. Intermittent hypoxia (IH) reflects an immature respiratory neuronal center and represents a
consequence of apnea. Previous studies have demonstrated that caffeine decreases the frequency of apnea and resultant IH.
OBJECTIVE: To determine the impact of caffeine on the frequency of IH episodes in VLBW infants.
DESIGN/METHODS: Infants < 1.5kg birth weight were studied over the first 6 weeks of life. High resolution (2s sample rate) pulse oximetry oxygen saturation was recorded and IH episodes were defined as oxygen
saturation ≤ 80% for ≥ 10s and < 3 minutes. Data were analyzed on 37 studies from 17 patients.
RESULTS: The number of IH events was high with a median of 12 per hour (range 6, 18). The number of IH events was inversely related to the caffeine dose (p=0.04).
Percent time with saturations <85% (p=0.01), <80% (p=0.04), and <75% (p=0.04) was also inversely related to the caffeine dose.
CONCLUSIONS: Both number of IH events and the percent time with saturations <85%, <80%, and <75% are inversely related to caffeine dose. We speculate that these data will impact the design of future clinical
trials to optimize caffeine dosing and enhance clinical outcomes in preterm infants.
Filename: 750801
Presenting Author: Josel A.A. Doyle, MD
Department/Institution/Address: Pediatrics, Stony Brook Children's Hospital, HSC-11-060, Division of Neonatal-Perinatal Medici, Department of Pediatrics, Stony Brook Children[apo, Stony Brook, 11794,
11794-8111, United States
Phone: 631-444-7653
Fax:
Title: Margin of Safety for Discharge of the Preterm Infant With Apnea of Prematurity: How Many Days Off Caffeine Is Enough Time?
Josel A.A. Doyle1, Dennis Davidson1, Susan Katz1, Marie Varela1, Catherine Messina2, Doreen DeMeglio1 and Joseph Decristofaro1. 1Division of Neonatal-Perinatal Medicine, Stony Brook Children's Hospital, Stony
Brook, NY and 2Department of Preventive Medicine, Stony Brook University Hospital, Stony Brook, NY.
BACKGROUND: Resolution of apnea of prematurity (AOP) is a prerequisite for the safe hospital discharge of a premature infant. Caffeine is commonly used to treat AOP; levels as low as 2.9 mg/L have been
associated with a therapeutic effect. Most often, caffeine is discontinued before discharge and then premature infants are monitored for variable duration of time for AOP.
OBJECTIVE: To determine the time course of caffeine levels after its discontinuation (d/c) and relate it to the recurrence of AOP prior to discharge.
DESIGN/METHODS: This was a prospective, cohort study. Premature infants with a gestational age ≤32 weeks were enrolled. The decision for caffeine discontinuation was made independently by the attending
physician on service. Oxypneumogram (OP) studies and caffeine levels were obtained 24h and 168h after the last dose of caffeine was given. OPs scores were based on either apneas >20secs or apneas <20secs
with associated bradycardia < 80 bpm for >5 secs with or without oxygen saturation <90% for >5 secs assigning 1 point for each event.
RESULTS: 48 infants were enrolled (GA =29 weeks ± 2.2, BW 1265 g ± 355; mean ± SD). D/C of caffeine occurred at a PCA of 35 weeks ± 1.3. Caffeine levels decreased from 13.4 mg/L ± 3.8 to 4.4 mg/L ± 2.1 at 24
and 168 h respectively (p< 0.001) The caffeine level ½ life was 85 ± 24h. At 7 days after D/C 68% of the patients had an abnormal OP. OP scores increased from 1.3 ± 1.8 to 2.1 ± 2.2 events at 24 and 168h,
respectively (p < 0.01). The average LOS after stopping caffeine was 17 ± 9days.
CONCLUSIONS: In this cohort, the mean caffeine level at 7 days after discontinuation was still in a therapeutic range. There was also a small but significant increase in pathologic apneas found after 7 days. Based on
the overall t ½ at discontinuation of caffeine for all study patients, infants would generally would need another 3-4 days for caffeine levels to drop to a sub-therapeutic value below 2.9 mg/L. Discharge planning for
premature infants treated with caffeine for apnea, should consider a 10 - 11 day waiting period after discontinuation of caffeine so that patients can be carefully monitored clinically or by pneumogram.
Filename: 753972
Presenting Author: Jennifer P. Alexander, MD
Department/Institution/Address: Neonatology, University of Maryland, 110 South Paca Street 8th Floor, Baltimore, MD, 21201, United States
Phone: (703)725-3862
Fax: (410)328-1076
Title: Sucrose During Heel Lance and Effect on Maternal Interaction, Social Behavior and Pain Thresholds in the Neonatal Rat
Jennifer P. Alexander1, Kristen A. Wellmann1 and Sandra M. Mooney1. 1Neonatology, University of Maryland, Baltimore, MD.
BACKGROUND: Infants in the NICU endure frequent painful procedures such as heel lances. Pain modulation is immature in neonates and exposure to pain during this time may alter the development of pain
pathways, leading to changes in pain thresholds and behavior. Sucrose is given to provide comfort, but it may not attenuate pain following repeated heel lances. In rats, pain can alter ultrasonic vocalizations (USVs),
maternal-pup interactions, and behavior.
OBJECTIVE: The objective of this study was to determine whether frequent pain during the neonatal period alters rat behavior and whether sucrose mitigates these effects.
DESIGN/METHODS: Long Evans rat pups were assigned to one of four groups (± pain; ± sucrose; 5-6 pups per sex per group). Pain groups were lanced on one hind paw daily on postnatal day (P) 3-P10. Sucrose
groups received oral sucrose prior to handling or lance. Pups underwent isolation (I-) USV and maternal retrieval testing on P12. On P28, animals underwent social interaction testing. Somatosensory function was
tested on P32 using a gap crossing test, and pain thresholds were measured using Von Frey hairs on P33. I-USV data were analyzed using a 3-way repeated measures ANOVA. For all other data a 3-way ANOVA
was performed.
RESULTS: Pups exposed to pain initially called at a lower rate than their no pain counterparts (p=0.057). Maternal retrieval showed that sucrose pups were retrieved later than no sucrose pups (p<0.05). During social
interaction, pain-exposed males made less contact than pain+sucrose rats (p=0.057). The gap crossing test was unaffected by pain or sucrose. The Von Frey hair test showed higher pain thresholds in the non-pricked
foot in pain-exposed animals compared to no pain rats (p<0.05), in males exposed to pain compared to females exposed to pain (p=0.067), and in sucrose-exposed rats compared to no sucrose rats (p=0.05).
CONCLUSIONS: Repeated pain in the neonatal period alters infant rat call frequency and results in decreased social contact and higher pain thresholds in males. Thus, pain may cause hypoalgesia. The effects in the
non-pricked foot suggest pain effects are mediated in the central nervous system rather than locally. Sucrose altered maternal-infant interaction and mitigated pain in pain-exposed groups. In summary, pain has both
short- and long-term consequences in behavior and nocioception, and these effects may be sex-specific. Sucrose may have some long-term therapeutic effects.
Filename: 751481
Presenting Author: Pratik Parikh, MBBS
Department/Institution/Address: Pediatrics, University of Rochester, 601 elmwood ave, rochester, NEW YORK, 14642, United States
Phone: 5852751847
Fax:
Title: A Comprehensive Pain & Sedation Initiative Reduces Opioid Exposure in the NICU
Pratik Parikh1 and Jeffrey M. Meyers1. 1Pediatrics, University of Rochester Medical Center, Rochester, NY.
BACKGROUND: Both inadequate pain and sedation control in neonates and excessive opioid exposure are associated with adverse outcomes in preterm and term infants. A goal of treatment is to achieve optimal
pain/sedation control while minimizing drug exposure.
OBJECTIVE: We sought to implement a standardized pain and sedation scale and novel treatment algorithm to optimize pain control and sedation and to assess the scale's accuracy and algorithm's adequacy to
detect and treat pain.
DESIGN/METHODS: A comprehensive pain and sedation initiative was developed over 5 months and implemented on 4/1/14. The initiative included pre and post-surveys to assess staff attitudes towards pain
management, a new pain and sedation scale (N-PASS: Neonatal Pain, Agitation & Sedation Scale), and a novel algorithm to guide opioid dosing and escalation and facilitate weaning of continuous infusions (CI) when
appropriate. Using a before and after design, all infants born in pre and post intervention cohorts were included for comparison, except those with length of stay (LOS) <7d. Primary outcomes included the frequency,
max dose and duration of CI and total cumulative opioid dose received from both CI and bolus dosing, and secondary outcome was LOS. Opioid dosing data were converted and expressed in morphine equivalents.
T-test, Mann-Whitney U-test, and chi-square test were used as appropriate.
RESULTS: Pre and post-intervention cohorts (n=298 vs 318, respectively) had similar mean BW (2274±971 vs 2196±970g) and GA (34.2±4 vs 34.4±4 wks). Need for HFV (9% vs 6%), incidence of PDA (8% vs 8%)
and NEC (4% vs 4%), and need for surgery (12% vs 10%) was similar between pre and post-intervention groups. Incidence of CI use decreased by 44% in the post versus pre-intervention periods (9% vs 16%,
p=0.01). Compared to the pre-intervention cohort, infants post-intervention received less cumulative opioids from boluses (3.8 vs 1.1 mg/kg, p<0.02) and CI (51.6 vs 14.8 mg/kg, p<0.02), less total opioids (57.7 vs
16.5 mg/kg, p<0.02) and had a lower max CI dose (0.65 vs 0.25 mg/kg/hr, p<0.01). Duration of CI was similar between groups. Median LOS decreased following implementation (18 vs 14d, p<0.02). Survey
respondents perceive better pain control post-implementation.
CONCLUSIONS: Implementation of a comprehensive pain and sedation assessment and treatment initiative decreased opioid exposure and may shorten LOS while obtaining adequate pain control and better staff
satisfaction with pain management.
Filename: 755760
Presenting Author: Anne Marie Abao, MD
Department/Institution/Address: Pediatrics, Flushing Hospital Medical Center, 4500 Parsons Boulevard, Flushing, New York, NY, 11355, United States
Phone: 17186705535
Fax:
Is Presenting Author a Trainee? Yes, Other - Resident Physician PGY3
Title: Usefulness of a Sepsis Protocol as a Screening Tool in an Urban Community Hospital
Anne Marie Abao1, Lily Quon Lew1, Dakshayani Guttal2, Susana Rapaport1 and Gagan Gulati1. 1Pediatrics, Flushing Hospital Medical Center, Flushing, NY and 2Pediatrics, Jamaica Hospital Medical Center, Jamaica,
NY.
BACKGROUND: Sepsis remains a formidable cause of mortality in the pediatric population. In April 2014, Flushing Hospital Medical Center (FHMC) instituted a sepsis protocol as a screening tool (ST) for early
recognition and treatment of sepsis in the emergency department (ED) in accordance to the New York State mandate for all hospitals. No prior studies have been done to demonstrate the usefulness of the sepsis
screening protocol in children and adolescents in FHMC.
OBJECTIVE: To demonstrate the usefulness of the ST in pediatric ED at FHMC.
DESIGN/METHODS: Retrospective chart review of patients age one month to 18 years visiting pediatric ED at FHMC with a chief complaint of fever between January 1 to December 31, 2013. Exclusion criteria were
absence of fever at triage, immunocompromised state and chronic illness. ST was applied to the included patients and the patients were divided into two groups. Sepsis screen positive was designated G1 and sepsis
screen negative G2. Data including demographics, vital signs, investigational studies, use of intravenous antibiotics (IVA), diagnosis and disposition were collected. SPSS 22 via cross table analysis was used to
compare the frequencies and percentages, p<0.05 was considered significant. ST sensitivity (sen), specificity (spec), positive likelihood ratio (+LR) and negative likelihood ratio (-LR) were also computed. A +LR>1
with a –LR approximating 0 was defined as useful.
RESULTS: Of 400 charts reviewed, 211 charts met the exclusion criteria. Of the remaining charts, 40 were in G1 and 149 were in G2. There were no statistical differences between G1and G2 for age, gender,
diagnosis and disposition, p>0.05. By cross table analysis, 25% of G1 had investigational studies compared to 24.2% of G2 (sen: 0.21; spec: 0.79 with +LR: 1, -LR: 1). Only 5% of G1 were given IVA compared to
4.7% of G2 (sen: .22; spec: .78, +LR:1, -LR:1). Positive blood culture was zero in G1 and two in G2.
CONCLUSIONS: Sepsis protocol as a ST did not prove to be useful in making decisions as to when to investigate or when to give IVA in our pediatric population. Each patient should continue to be assessed
individually in addition to using ST.
Filename: 750854
Presenting Author: Jennifer E. Sanders, MD
Department/Institution/Address: Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Place, Box 1149, New York, New York, 10029, United States
Phone: 2052756783
Fax:
Title: The Effect of Point-of-Care Ultrasound on Emergency Department Diagnosis and Management of Cellulitis Versus Local Allergic Reaction from Insect Bites
Jennifer E. Sanders1, James W. Tsung1 and Ee T. Tay1. 1Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
BACKGROUND: Clinically distinguishing cellulitis from angioedema caused by a bite or sting can be difficult. The diagnostic uncertainty may lead to misdiagnosis and the misuse of antibiotics (ABX). The sonographic
findings of cellulitis have been well described, but to date, only a small case series can be found that describes the appearance of allergic reactions/angioedema from insect bites. Soft tissue ultrasound (US) may lead
to better differentiation between cellulitis and allergic reactions (AR), and improve ABX stewardship.
OBJECTIVE: To evaluate the effect of soft tissue US on management of soft tissue swelling in emergency department (ED) patients with insect bites.
DESIGN/METHODS: This was a prospective study in a pediatric ED of patients ≤21 years old, with clinical soft tissue swelling from insect bites. Treating physician's pretest opinions regarding the diagnosis and need
for ABX were determined. Trained ED physicians performed an US of the affected area, and the effect on management plan was recorded. We defined cellulitis on US as thickened skin, and the presence of soft
tissue lobules with surrounding fluid, known as “cobblestones”. Angioedema was defined as the presence of multiple, linear, horizontal and striated hypoechoic bands within the tissue. Further imaging, medications
and disposition were at the discretion of the enrolling physician. Phone call follow up was made within a week of the initial presentation.
RESULTS: Among 103 enrolled patients, 16 had cellulitis (15.5%). Mean age was 7 years (±6yr), 50.5% were male. US changed the management of patients with soft tissue swelling secondary to insect bites in
27/103 (26%; 95% CI = 18% to 35%) of patients. Of the patients who were believed to require ABX prior to the test, US changed management in 6/26 (23%; 95% CI = 6% to 40%) of patients. In those patients who
were not believed to require ABX prior to the test, US changed management in 12/77 (16%; 95% CI = 7% to 24%). On average, patients with a diagnosis of an AR achieved symptom resolution 1.4 days sooner than
patients with a diagnosis of cellulitis (mean= -1.389, 95% CI -2.094 to -0.705; p=<0.001). No patient diagnosed with AR subsequently required ABX upon follow up visit.
CONCLUSIONS: Soft tissue US changes physician management in approximately 25% of patients in the ED with soft tissue swelling secondary to insect bites, and may improve recognition of early cellulitis.
Filename: 750103
Presenting Author: Ashley C. Notartomaso, MD
Department/Institution/Address: Department of Pediatrics, St. Joseph's Regional Hospital Medical Center, 703 Main Street, Paterson, NJ, 07503, United States
Phone: 9737542544
Fax:
Title: Performance of Non-Contrast MRI in Evaluation of Appendicitis in Children
Ashley C. Notartomaso1, Edward Milman3, Robin Frank-Gerszberg3, Warren B. Freitag3, Nileshwari M. Patel2 and Michael Gorn2. 1Department of Pediatrics, St. Joseph's Regional Hospital Medical Center, Paterson,
NJ; 2Department of Emergency Medicine, St. Joseph's Regional Hospital Medical Center, Paterson, NJ and 3Department of Radiology, St. Joseph's Regional Hospital Medical Center, Paterson, NJ.
BACKGROUND: Appendicitis is a common surgical cause of abdominal pain in children. Ultrasound (US) and computed tomography (CT) are routinely used for diagnosis. Magnetic resonance imaging (MRI) has been
postulated as an alternative; however, protocols may require contrast and are lengthy. Diagnostic characteristics of non-contrast Fast Sequence Abdominal MRI (FsaMRI) have not been prospectively evaluated for
suspected appendicitis in children.
OBJECTIVE: To describe the performance characteristics of non-contrast Fast Sequence Abdominal MRI(FsaMRI). To retrospectively evaluate a protocol of US and selective MRI imaging in a sample of children with
suspected appendicitis.
DESIGN/METHODS: Prospective trial in children <18 years old with acute abdominal pain. FsaMRI was performed in addition to standard workup (US and/or CT) in all patients. MRI was interpreted by 3 radiologists
who were blinded to other imaging and clinical outcomes. Equivocal MRI readings were eliminated from modality analysis. MRI was equivocal if normal appendix was not visualized and other findings were present to
suggest the need for further workup. Clinical outcome was established by surgical pathology review; inpatient records, and phone follow-up for patients who were discharged.
RESULTS: 104 patients were enrolled, 84(81%) completed the study. Mean age was 12yr(SD ± 3), 37(48%) were male, and 30(39%) had appendicitis. All patients had FsaMRI; 23(27%) had US alone, 14(17%) had
CT alone, and 47(56%) had both. MRI was equivocal in 7(8.3%) cases, 77(92%) patients were eligible for analysis. Test characteristics were - CT: sensitivity 100%(95%CI 78-100%), specificity 95%(95%CI 83-99%);
US: sensitivity 77%(95%CI 56-90%), specificity 89%(95%CI 75-96%); FsaMRI: sensitivity 90%(95% CI 72-97%), specificity 98%(95% CI 87-100%), PPV 96%(95%CI 80-100%), NPV 94%(95%CI 82-98%). Of the 7
equivocal cases of MRI, 2 had appendicitis. There were also 3 cases of false negative FsaMRIs. If a protocol of US followed by FsaMRI was undertaken, 3 of these 5(60%) cases would be identified on US alone, 1
patient would be sent for a CT, and 1 of 31(3.2%) total cases of appendicitis would be missed. Overall, 4 of 84(4.8%) vs 61(73%) patients would get a CT.
CONCLUSIONS: Non-contrast FsaMRI is a useful modality to evaluate for appendicitis in children. US/FsaMRI followed by CT for equivocal cases may be used as routine in evaluation of children with suspected
appendicitis.
Filename: 754193
Presenting Author: Jeffrey Dela Cruz, MD
Department/Institution/Address: Emergency Medicine, NYU SOM / Bellevue Hospital Center, 27th Street and First Ave Dept EM, Room 345, New York, NY, 11050, United States
Phone: 516-987-5401
Fax: 212-562-2474
Title: Knowledge and Prevalence of Pertussis Booster Vaccine Among Emergency Department Healthcare Personnel
Jeffrey Dela Cruz1, Jung-Eun Ha1 and Deborah A. Levine2. 1Emergency Medicine, NYU SOM/Bellevue Hospital Center, New York, NY and 2Emergency Medicine and Pediatrics, NYU SOM / Bellevue Hospital Center,
New York, NY.
BACKGROUND: Pertussis is a common vaccine-preventable disease that is on the rise in the United States. Infection can lead to devastating consequences especially in young infants. Protection from childhood
vaccination decreases over time, leaving many adults at risk for disease , such as emergency department (ED) healthcare providers. Those infected can unknowingly transmit infection to patients and the community.
The Centers for Disease Control and Prevention (CDC) recommended that all healthcare personnel receive the pertussis booster vaccine.
OBJECTIVE: Our objective was to assess pertussis booster status, barriers to vaccination and knowledge of pertussis and its vaccine in two urban hospital ED healthcare personnel.
DESIGN/METHODS: A anonymous paper survey was distributed to ED healthcare personnel after verbal consent was obtained. The survey included questions about ED position, hospital workplace, direct patient
care, vaccine status, pertussis knowledge, vaccine adverse effects and influenza vaccine status.
RESULTS: Three-quarters of participants reported being up to date with their pertussis vaccine; this rate was highest among registered nurses and lowest among ancillary staff (non-physicians and non-nurses).
Personnel who received influenza vaccine were not more likely to get a pertussis booster. Most (74.8%;80/107) personnel who had not received the booster or did not know about their status were willing to receive if
given at work free of charge.
Position/Workplace Booster Yes (%) Booster No (%) Booster Unknown (%)
Totals
294 (73.3%)
46 (11.5%)
61 (15.2%)
MD
90 (72.6%)
13 (10.5%)
21 (16.9%)
RN
130 (85.0%)
7 (4.6%)
16 (10.5%)
Ancillary staff
74 (59.7%)
26 (21.0%)
24 (19.4%)
University hospital
154 (81.1%)
16 (8.4%)
20 (10.5%)
Municipal hospital
59 (57.3%)
21 (20.4%)
23 (22.3%)
Both hospitals
81 (75.0%)
9 (8.3%)
18 (16.7%)
Variables
Relative Risk: Booster Yes vs. No/Unknown (95%CI)
Influenza vaccination status
1.00 (0.94-1.07)
Knowledge of pertussis
1.85(1.01-3.40)
Knowledge of CDC recommendation 1.14 (1.04-1.25)
Knowledge of booster duration
0.96 (0.44-2.09)
CONCLUSIONS: Increased education of healthcare personnel is needed to encourage compliance with CDC recommendations. Hospital administration should actively educate healthcare staff and encourage
pertussis booster vaccine administration. The mandatory influenza vaccine campaign at many hospitals through the country may be a vehicle to increase pertussis vaccine compliance.
Filename: 750415
Presenting Author: Megan E. Maraynes, MD
Department/Institution/Address: 541 Dean Street, Brooklyn, NY, 11217, United States
Phone: 19144190533
Fax:
Title: Screening for Chlamydia and Gonorrhea in Young Males Seeking Care in an Urban Pediatric Emergency Department
Megan E. Maraynes1, Jennifer H. Chao1, Shahriar Zehbtachi1 and Konstantinos Agoritsas1. 1Emergency Medicine, Division of Pediatric Emergency Medicine, SUNY Downstate College of Medicine, Kings County
Hospital Center, Brooklyn, NY.
BACKGROUND: Chlamydia Trachomatis (CT) and Neisseria Gonorrhea (GC) are the most common bacterial sexually transmitted infections (STI) among sexually active adolescents, especially in African American
and low socio-economic populations. Both CT and GC are frequently asymptomatic, especially in males. Little is known about the prevalence of asymptomatic STI in adolescent males. Adolescents do not utilize
primary care frequently, and are often seen for acute issues in the emergency department setting, thus minimizing screening opportunities.
OBJECTIVE: To determine the prevalence of asymptomatic CT and GC in young men seeking care in the emergency department (ED) for non-STI related symptoms.
DESIGN/METHODS: Prospective, cross-sectional pilot study in an urban ED. Inclusion criteria: males age 16-21 presenting with non-STI related complaints. Exclusion criteria: genitourinary or STI-related complaints
at triage, current antibiotic therapy, and high acuity level (Emergency Severity Index 1-3). Outcome: rate of positive CT and GC. Patients were tested for CT and GC (gen-probe urine RNA assay) after obtaining written
informed consent. Data are presented as medians with quartiles for continuous variables and as percentages with 95% confidence intervals for proportions. Descriptive statistics are used to report data.
RESULTS: Of 208 patients approached, 176 were enrolled (age range 16-21, median: 18 [quartiles 16-18, 19-21]). Overall, 8% (95% CI, 5 - 13%) tested positive for CT and 0% (95% CI, 0 - 3%) were found to have
GC. The proportion of sexually active subjects was 90% (95%CI, 85 - 94%), and 2% (95%CI, 0.7 - 6%) reported sex with men. Previous STI testing was reported in 64% (95%CI, 57 - 61%) of enrolled subjects, and
13% (95%CI, 8 - 21%) of those patients had a history of positive STI results. Of the patients who tested positive 78% (95%CI, 52 - 93%) were successfully followed up and treated.
CONCLUSIONS: The rate of positive CT infection (8%) found by screening of asymptomatic young men in the emergency department is relatively high. The findings of this study justify routine STI screening in young
adolescents presenting to the ED with non-STI related complaints.
Filename: 754119
Presenting Author: Christopher M. Mashiak
Department/Institution/Address: Molecular and Cell Biology, University of Connecticut, 91 North Eagleville Road, Unit 3125, Storrs, CT, 06269, United States
Phone: 8604864329
Fax:
Title: Predictability of an ED-Screening Tool for Future Exposure To Violence
Christopher M. Mashiak1, Christine H. Mulvey2, Sharon R. Smith2 and Steven C. Rogers2. 1Department of Molecular and Cell Biology, University of Connecticut, Storrs, CT and 2Department of Emergency Medicine,
Connecticut Children's Medical Center, Hartford, CT.
BACKGROUND: An epidemic of violence is currently affecting children within the United States. Unfortunately, an effective way to identify children at risk for violence has not been developed. The Violence Prevention
Emergency Tool (VPET) was designed to detect such youth so proper interventions may be provided. VPET has previously been tested to show the viability of administering a violence risk questionnaire in the
Emergency Department (ED).
OBJECTIVE: To establish VPET's predictive value for exposure to violence in order to identify children at risk.
DESIGN/METHODS: English and Spanish speaking children age 8 through 17 were enrolled in a prospective questionnaire-based study. During their visit to an urban Pediatric ED, they were administered VPET, a 7
item questionnaire. Items predict the probability of patient's exposure as a victim, a perpetrator, or a witness of violence. Follow-up questions were asked 3 and 6 months post enrollment by telephone. All questions
were asked while the child was in a private location.
RESULTS: Upon interim analysis, 373 children consented and completed VPET. Of these children, 46% were reached for the 3 month follow-up, and 35% for the 6 month. The children where 53% male, 27% African
American, and 67% Hispanic/Latino. The mean age of participants was 12.3 years (SD=2.9). Six out of seven VPET items showed significant odds ratios (OR) with future violent exposures. The questionnaire item
numbers and question content are listed along with the association to the type of violence.
Table 1: Associations at 3 Month Follow-Up
VPET Item (Over the past year)
1. Been injured by someone
2. Chased by an angry person
3. Injured someone
5. Physically harmed by another that caused injury
6. Had a person steal stuff from you
7. Stolen, anything, sold drugs, or destroyed property
Exposure OR 95% CI
Witness
2.77 1.29-5.97
Victim
2.90 1.54-5.47
Victim
2.67 1.39-5.13
Perpetrator 2.42 1.27-4.64
Victim
2.68 1.30-5.08
Victim
2.56 1.30-5.08
Witness
3.17 1.53-6.55
*All items p<0.01.
Analysis on six month follow-up showed similar results.
CONCLUSIONS: Six of the seven items on VPET show predictive value in some form of violence exposure either as witness, victim, or perpetrator. Further analysis is required as the enrollment in this study is
ongoing for a full sample size of 600 children.
Filename: 753962
Presenting Author: Roselle Vittorino, M.D.
Department/Institution/Address: Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, 630 West 168th Street, CHN-517, New York, NY, 10032, United States
Phone: 347-393-2384
Fax:
Title: Gardnerella Vaginalis Induces Intra-Amniotic Inflammation in a Murine Model of Ascending Infection During Pregnancy
Roselle Vittorino1, Leah M. Byland1, Shari E. Gelber2, Tara M. Randis1 and Adam J. Ratner1. 1Pediatrics, Columbia University Medical Center and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York,
NY and 2Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY.
BACKGROUND: Bacterial vaginosis (BV) is a significant risk factor for preterm birth. While BV is best understood as a vaginal dysbiosis, Gardnerella vaginalis is the primary etiological agent and has been isolated
from the amniotic fluid in pregnancies complicated by preterm labor. The mechanisms by which G.vaginalis ascends and invades the intra-amniotic cavity are poorly understood. We hypothesize that vaginolysin
(VLY), the major pore-forming toxin produced by G. vaginalis may play a critical role.
OBJECTIVE: We sought to develop a murine model of ascending G. vaginalis infection during pregnancy and to examine the specific role of VLY in inducing adverse pregnancy outcomes.
DESIGN/METHODS: We vaginally colonized timed-pregnant female C57BL6/J mice on day 13 of pregnancy (E13) with G. vaginalis. In order to investigate the unique contribution of VLY, we also colonized transgenic
mice that express the human specific, VLY receptor (CD59). Animals were monitored daily for weight gain and preterm delivery. On E17, dams were sacrificed and feto-placental units harvested to determine the
extent of microbial invasion by culture and quantitative real-time PCR (qPCR) analysis. Amniotic fluid was collected and interleukin-6 (IL-6) concentration was quantified by ELISA.
RESULTS: Placental infection with G. vaginalis was documented following vaginal colonization of both wild type (7 of 11 dams) and transgenic mice (2 of 3 dams), as evidenced by both culture and qPCR. Preterm
delivery and/or intrauterine fetal demise did not occur in either group. The average amniotic fluid IL-6 concentration was elevated in infected transgenic animals (655.3 pg/ml), but was similarly low in both wild type
infected and sham-infected mice (185.1 vs 146.5 pg/ml, P>0.05).
CONCLUSIONS: Ascending G. vaginalis infection during pregnancy induces an intrauterine inflammatory response that is mediated by VLY. These findings represent the first demonstration of this pore-forming toxin's
virulence in vivo. This novel murine model of ascending G.vaginalis infection serves as valuable tool to explore bacterial-host interactions underlying the pathogenesis BV-associated preterm birth.
Filename: 751153
Presenting Author: Birju A. Shah, MD, MPH
Department/Institution/Address: Pediatrics, Women and Infants' Hospital of Rhode Island, The Alpert Medical School, 101 Dudley Street, Providence, Rhode Island, 02905, United States
Phone: 4012841122
Fax: 401-453-7571
Title: Development of Point-of-Care Rapid Test of Inter-alpha Inhibitor Proteins for Early Detection of Neonatal Sepsis
Birju A. Shah1, Jeff Hall2, Andre Santoso3, Joseph Qui3, Yow-Pin Lim3 and James Padbury1. 1Pediatrics, Women and Infants Hospital, The Alpert Medical School of Brown University, Providence, RI; 2BioActive Labs,
Inc., Frankliin, MA and 3ProThera Biologics, Inc., East Providence, RI.
BACKGROUND: Neonatal sepsis is an important cause of morbidity and mortality in newborns and early diagnosis remains challenge because the clinical signs are non-specific. Currently, there is no reliable rapid
point-of-care marker available. Inter-alpha inhibitor proteins (IAIP) are critical part of body's innate immune system and their circulating levels are significantly reduced in neonatal sepsis.
OBJECTIVE: To develop a quantitative competitive point-of-care rapid lateral flow immunoassay of IAIP to diagnose acute life threatening systemic inflammatory diseases.
DESIGN/METHODS: A widely used lateral flow rapid test concept consisting of overlapping sample pad, conjugate pad, nitrocellulose and terminal wick contained in a plastic cassette with sample well and a read
window is utilized. Purified human plasma-derived IAIP is immobilized on nitrocellulose strips. Monoclonal antibody against human IAIP (MAb 69.26) is conjugated to colloidal gold particles and used as a detection
agent. Diluted plasma samples are added in the wells. A standard curve is established by using IAIP calibrators with known concentrations. Collected plasma samples from infants with suspected neonatal sepsis and
non-septic controls are used to analyze the performance of rapid test.
RESULTS: After optimizing reagent/buffer formulations and assay conditions, rapid assay has been developed. It is capable to accurately measure IAIP ranging from 50 to 500 µg/mL in <10 min.
Plasma IAIP values from infants with suspected sepsis measured by the rapid test and established competitive ELISA demonstrated a correlation coefficient of 0.91 (n=51).
CONCLUSIONS: A point-of-care rapid test based on circulating IAIP level in blood has been successfully developed with results comparable to the established ELISA results and completed in <10 minutes. This rapid
test is potentially useful to identify neonatal sepsis in high-risk infants in a simple, user-friendly and portable device suitable for use in the NICU setting.
Filename: 751966
Presenting Author: Indirapriya Darshini Avulakunta, MBBS
Department/Institution/Address: Pediatrics, State University of New York at Buffalo, 219 Bryant St, Buffalo, NY, 14222, United States
Phone: +17168787673
Fax:
Title: Impact of Induction of Labor (ACOG) and Chorioamnionitis (AAP) Guidelines on NICU Admissions in Erie County, NY
Indirapriya Darshini Avulakunta1, Lisa Licare2, Vikramaditya Dumpa1 and Satyan Lakshminrusimha1. 1Pediatrics, University at Buffalo, Buffalo, NY and 2Obstetrics and Gynecology, University at Buffalo, Buffalo, NY.
BACKGROUND: In 2009, ACOG revised its guidelines recommending against elective induction of labor(IOL) prior to 39w gestational age(GA) (Obstet Gynecol 2009;114:386-97). We have previously shown that in
Erie County, NY, the NICU admissions were significantly greater in early-term (ET, 37-38wk GA) neonates compared to full-term or late-term (FLT 39-41wk GA) (JAMAPediatr.2013;167(11):1053). Around the same
period, AAP released guidelines on management of newborns born to women with maternal chorioamnionitis (MC) recommending empirical treatment of all these infants with antimicrobial therapy.
OBJECTIVE: To evaluate the impact of ACOG IOL guidelines on frequency of ET births and NICU admissions.
DESIGN/METHODS: This population-based retrospective study (2006-13) involved all births and NICU admissions in Erie County, NY. This period was divided into two epochs:pre-ACOG guidelines(2006-8) and
post-ACOG guidelines(2011-13). Detailed chart analysis of indications for admission to NICU at Women and Children's Hospital of Buffalo (WCHOB) was performed.
RESULTS: There was a significant decrease in ET births and increase in FLT births following implementation of ACOG guidelines. Overall admissions to NICU and ET admissions did not change but FLT NICU admits
increased in 2011-13.
Erie County Data
2006-08
2011-2013 (*p<0.05 cf. 2006-8)
Total Births
33488
33152
ET
9031(27%)
7664(23.1%)*
FLT
20633(61.5%) 21927(66.1%)*
Total NICU admits
4352(13%)
4503(13.6%)
ET admits (% of all ET births)
854(9.5%)
790(10.3%)
FLT admits (% of all FLT births)
1102(5.3%)
1380(6.2%)*
The number of NICU admits due to MC increased in the post ACOG guideline period with a significant increase in proportion of asymptomatic newborns admitted due to maternal chorioamnionitis (AMC).
WCHOB Data
2006-08
Term NICU Admissions(ET+FLT)
927 (378+549) 1108 (457+651)
2011-13 (*p<0.05 cf. 2006-8)
Admissions due to MC(% of term admissions)
24(2.5)
139(12.5)*
AMC(% of term admissions)
9(0.9)
76(6.8)*
AMC-ET(% of ET admissions)
3(0.8)
21(4.6)*
AMC-FLT(% of FLT admissions)
6(1.1)
55(8.4)*
CONCLUSIONS: ACOG guidelines of restricting elective IOL or cesarean delivery to ≥39 wk GA effectively decreased ET births in Erie County,NY. However, this decrease did not translate to reduction in NICU
admissions partly due to an increased number of admissions of infants with MC, adhering to the AAP recommendations to reduce early-onset sepsis.
Filename: 754314
Presenting Author: Hazel Villanueva, MD
Department/Institution/Address: Pediatrics, Stony Brook Children's Hospital, 101 Nicolls Rd, Stony Brook, NY, 11794, United States
Phone: 631-444-7653
Fax:
Title: Acute Hypoxia Induces Cytokine Synthesis and Release in Mouse Pheochromocytoma Cells – A Potential Protective Mechanism To Hypoxic Stress
Hazel Villanueva1, Priyadarshani Giri1 and Marian Evinger1. 1Pediatrics, Stony Brook Children's Hospital, Stony Brook, NY.
BACKGROUND: Acute hypoxia stimulates release of adrenal catecholamines (CAs) and neuropeptides to counteract the adverse metabolic and physiologic effects of this stress. In neonates, adrenal medullary cells
function as oxygen (O2) sensors prior to maturation of the sympathetic nervous system. Hypoxia evokes a rapid release of epinephrine (Epi) and enkephalin from these cells. Interleukin-1 alpha (IL-1α) and
interleukin-1 beta (IL-1β) regulate secretion of CAs from adrenal chromaffin cells. However, it has not been determined whether acute hypoxia influences synthesis or release of IL-1α and IL-1β, thereby potentially
affecting the neonate's response to hypoxic episodes. Because mouse pheochromocytoma cells (MPC 10/9) express features of developing chromaffin cells, they provide an experimental system to investigate
hypoxia response mechanisms in adrenergic cells.
OBJECTIVE: To determine if acute hypoxia stimulates synthesis and secretion of IL-1β and IL-1α in MPC 10/9 cells.
DESIGN/METHODS: MPC 10/9 cells were subjected to hypoxic conditions (10% O2) for intervals of 0,15,30,45, and 60 min. IL-1α and IL-1β were quantified in cell extracts and media via Luminex assay using mouse
specific antibodies. Cytokine mRNAs were assessed using reverse transcriptase-mediated polymerase chain reaction (RT-PCR).
RESULTS: IL-1β and IL-1α are present in MPC 10/9 cell extracts at 4.3(±2.1) and 1.2(±0.8)pg/µg protein. After 15min exposure to hypoxia, 1lL-1β content increases 50% to 6.5(±1.5)pg/µg. A parallel increase in IL-1β
mRNA also occurs. IL-1α cellular content increases to 1.5 (±0.7)pg/µg during this interval. Hypoxia stimulates release of both IL-1β and IL-1α, with maximal secretion at 30 min.
CONCLUSIONS: Hypoxia evokes the synthesis and release of IL-1β and IL-1α in chromaffin cells. In contrast to the previously-demonstrated rapid release of Epi and enkephalin (maximal at 15 min), hypoxia evokes a
slower release of IL-1β and IL-1α. Although these cytokines can acutely inhibit catecholamine release, their longer-term autocrine influence includes enhanced catecholamine release. In hypoxic MPC 10/9 cells,
delayed cytokine release may thus permit an initial, essential Epi bolus while still permitting a subsequent catecholamine response to recurring hypoxic events. This can be a potential protective response mechanism
in neonatal adaptation during acute oxygen deprivation.
Filename: 751586
Presenting Author: Kaitlin McLean, MD
Department/Institution/Address: Neonatology, Christiana Care Health System, 4745 Ogletown Stanton Road, Newark, DE, 19713, United States
Phone: 3027332410
Fax: 3027332602
Title: Lack of Efficacy of Antenatal Corticosteroids in IUGR Infants
Kaitlin McLean1,2, David A. Paul1,2, Shivaprasad Goudar3, Nancy L. Sloan1, Amy Mackley1, Richard Derman1, Fran Jaeger1, Dana Thompson1, Haritha Vellanki1,2 and Robert Locke1,2. 1Neonatology &
Obstetrics-Gynecology, Christiana Care Health System, Newark, DE; 2Neonatology/Pediatrics, Jefferson Medical College, Philadelphia, PA and 3Women's & Children's Health Research Unit, Jawaharlal Nehru Medical
College, Belgaum, Karnataka, India.
BACKGROUND: Antenatal corticosteroid (ACS) treatment for women at risk for preterm delivery effectively reduces neonatal mortality and morbidity. Recent data suggests that in developing nations with high rates of
intrauterine growth restriction (IUGR) and uncertain gestational ages, ACS treatment is associated with increased neonatal mortality. Several retrospective studies in the United States and Canada demonstrate a lack
of efficacy of ACS treatment in mothers with infants with IUGR.
OBJECTIVE: Evaluate effect of ACS on mortality in very low birth weight IUGR infants.
DESIGN/METHODS: Retrospective review of infants born between 2002-2012 with gestational age ≥23 weeks and birthweight 450-1500g at a single level 3 perinatal referral center. Mothers were considered exposed
if they received any dose of ACS. IUGR was defined by OB diagnosis of restricted antenatal growth. Generalized linear model controlled for gestational age and multiple gestation.
RESULTS: In the study cohort (n=2346), mean GA 28±2.8 weeks (range 23-38 weeks), mean BW 1051±284g range (451-2377g), 28.3% multiple gestation, 11.5% were IUGR, and 65.8% of infants received ACS.
ACS treatment in VLBW IUGR infants showed no survival benefit (OR=1.318, 95% CI 0.552-3.144). ACS was associated with lower risk of mortality in VLBW infants without IUGR (OR=0.640, 95% CI 0.518-0.790).
95%
Exp(B) Mortality Confidence
Interval
Variable
Lower Upper
IUGR
Not IUGR
Antenatal steroids
1.318
0.552 3.144
No antenatal steroids 1
-
Antenatal steroids
0.518 0.790
0.640
No antenatal steroids 1
-
-
CONCLUSIONS: ACS treatment in VLBW IUGR infants showed no reduction in mortality. This differs from infants without IUGR where ACS lowered the risk of mortality. ACS may have differential benefit in
sub-populations; e.g. IUGR infant, malnutrition and uncertain gestational ages. Understanding risk and benefit nuances of ACS in these sub-groups is an important area for future study. We speculate that lack of
benefit may be due to pre-existing endogenously elevated cortisol levels in stressed IUGR fetuses or other competing untoward consequences specific to the ACS+IUGR population (e.g. cardiovascular remodeling)
that counteract ACS beneficial effects. Delaying delivery of stressed IUGR fetuses to allow for ACS treatment needs further investigation.
Filename: 752658
Presenting Author: C. Briana Bertoni, MD
Department/Institution/Address: Department of Neonatology/ Pediatrics, Thomas Jefferson University/ Nemours, 111 S 11th Street, Philadelphia, PA, 19107, United States
Phone: 302-660-1583
Fax:
Title: Meconium Stained Amniotic Fluid and Depressed Neonates: Does Presence of Meconium Below the Cord Changes Outcomes?
C. Briana Bertoni1 and Zubair H. Aghai1. 1Department of Neonataology/ Pediatrics, Thomas Jefferson University/ Nemours, Philadelphia, PA.
BACKGROUND: Approximately 5% of infants withmeconium stained amniotic fluid (MSAF) develop meconium aspiration syndrome (MAS). Despite limited data, current Neonatal Resuscitation Program (NRP)
guidelines recommend endotracheal (ET) suctioning at birth for all non-vigorous infants with MSAF. A recent pilot clinical trial from a developing nation did not show improved outcomes with ET suctioning infants with
MSAF who were depressed at birth.
OBJECTIVE: To study infants with MSAF who are depressed at birth and required ET suctioning and compare the outcomes of those with versus those without meconium below the cords.
DESIGN/METHODS: This is a retrospective data analysis of infants with MSAF born between October 2006 and March 2014, and admitted to the NICU. Infants were divided into two groups, meconium aspirated
versus no meconium aspirated from below the cords. Demographic, clinical parameters and respiratory outcomes were compared between the two groups.
RESULTS: A total of 981 infants with MSAF were admitted to the NICU. ET suction was performed in 281 (28.6%) infants. 22 were excluded secondary to lack of documentation on whether meconium was present
below the cords. Of 259 infants with ET suction, 152 (58.7%) had meconium below the cords and 107 (41.3%) infants had no meconium below the cords. There was no significant difference in BW, GA, cord pH and 5
minutes apgar scores between the two groups. More infants with meconium below the cords had respiratory distress, required any respiratory support and mechanical ventilation.
Table: Demographics and outcomes in neonates with MSAF and ET suction.
Meconium Below the cord No Meconium below the cord
p-value
(n=152)
(n=107)
BW (kg) (mean±SD)
3.341±0.62
3.342± 0.59
0.9
GA (w)
39.3±1.9
39.2± 1.9
0.8
Respiratory Distress (%)
130 (85.5)
65 (60.8)
<0.001
Any respiratory support (%) 90 (59.2)
49 (45.8)
<0.001
Mechanical Ventilation (%)
37 (24.3)
15 (14.0)
0.04
NO Use (%)
18 (11.8)
7 (6.54)
0.2
ECMO (%)
7 (4.61)
3 (2.80)
0.5
Death (%)
3 (1.97)
4 (3.74)
0.5
CONCLUSIONS: With use of current NRP guidelines, a large number of depressed neonates with MSAF received ET suctioning even when there was no meconium below the cords. Despite ET suctioning, the
respiratory morbidities were significantly more in infants with mecomium below the cords. A large randomized clinical trial is needed to assess the safety and efficacy of ET suctioning in non-vigorous infants with
MSAF.
Filename: 751783
Presenting Author: Cristina Fernandez, MD MPH
Department/Institution/Address: Pediatrics, Columbia University Medical Center, 630 West 168th Street, PH 17-119, New York, NY, 10032, United States
Phone: 212-342-5730
Fax:
Title: Association of Dual Food and Energy Insecurity With Adverse Child Behaviors and Health
Cristina Fernandez1, Yang Jiang2, Melissa Stockwell1 and Yumiko Aratani2. 1Pediatrics, Columbia University Medical Center, New York, NY and 2Columbia University Mailman School of Public Health, New York, NY.
BACKGROUND: Food insecurity is associated with adverse child development and health. Poverty markers, such as energy insecurity, can increase risk of food insecurity and poor health. Although a “heat or eat”
effect, when families decrease food intake due to increased energy costs, has been demonstrated, few studies have examined the impact of dual food and energy insecurity on child health.
OBJECTIVE: To determine prevalence of dual food and energy insecurity and its association with adverse child health and behavior outcomes at age 9 years.
DESIGN/METHODS: Cross-sectional data from the last wave (age 9 years) of the national Fragile Families and Child Wellbeing Study (2007-2010) were analyzed. Food insecurity (yes/no) was measured by receipt of
free food and hunger with lack of money for food. Energy insecurity (yes/no) was measured by inability to pay utility bill and utility shut-off. Outcome measures, by caregiver self-report, were child health, asthma
diagnosis, asthma control status, emergency room (ER) visits, and behavior problems. The validated Child Behavior Checklist/6-18 classified aggressive, anxiety/depression, and withdrawn behavior scales with items
scored 0 (not true), 1 (somewhat true), and 2 (very true). Multivariate and ordinal logistic regression models assessed associations between dual food and energy insecurity and outcomes, adjusting for covariates
chosen a priori and by significant bivariate analyses. These included caregiver income, employment, marriage, education, primary language, and child gender and health insurance.
RESULTS: Of 3,565 families, 9.3% (n=332) had dual food and energy insecurity. Food insecure families had greater odds of being energy insecure (unadjusted odds ratio (OR) 3.9; 95% CI: 3.2-4.7). Dual food and
energy insecurity was associated with higher scores on anxiety/depression behavior scale (adjusted OR=2.1; 95% CI: 1.5-2.9) and withdrawn behavior scale (AOR=2.0; 95% CI: 1.6-3.3). Children with dual food and
energy insecurity had greater odds of poor health (AOR=2.2; 95% CI: 2.2-2.3) and increased ER visits (AOR=1.5; 95% CI= 1.1-2.1) versus those with security. No significant association was found between dual food
and energy insecurity and asthma diagnosis, asthma control, or aggressive behavior scale scores.
CONCLUSIONS: Children with dual food and energy insecurity had greater odds of poor health, increased number of ER visits, and higher scores on anxiety/depression and withdrawn behavior scales.
Filename: 750316
Presenting Author: Elaine Lin, MD
Department/Institution/Address: Pediatrics, Mount Sinai Medical Center, One Gustave L.Levy Place, Box 1202A, New York, NY, 10029, United States
Phone: 212-241-5023
Fax:
Title: Evaluation of a Multidisciplinary Home Visiting Program for Children With Special Health Care Needs
Elaine Lin1, Maureen Braun1, Susann Cortes2, Sanite Theophile1 and Joseph Truglio1,3. 1Pediatrics, Icahn School of Medicine at Mount Sinai Medical Center, New York, NY; 2Social Work, Division of Women and
Children's Health, Mount Sinai Medical Center, New York, NY and 3Medicine, Icahn School of Medicine at Mount Sinai Medical Center, New York, NY.
BACKGROUND: Children with special health care needs (CSHCN) often have unmet medical and social needs and frequently receive fragmented care. Evidence suggests that home visitation and care coordination
can improve health outcomes for CSHCN, however, few studies have examined a physician-led multidisciplinary team delivering comprehensive home-based care to CSHCN.
OBJECTIVE: To develop and evaluate a physician-led home visiting program for CSHCN.
DESIGN/METHODS: Children with poorly controlled asthma, children with medical complexity, and infants discharged from the neonatal intensive care unit (NICU), who live in East and Central Harlem are being
recruited from the outpatient clinic at an urban academic medical center. A team of two pediatricians, one social worker and one patient navigator provides medical and psychosocial care at home as well as care
coordination, including collaboration with ancillary services, community agencies, and subspecialty providers. Infants are enrolled for 6 months, asthma patients for 1 year, and medically complex children are followed
until transition to adult care. Healthcare utilization rates were reviewed for children who have been enrolled in the program for at least 3 months and received more than 1 home visit. Equal pre and post enrollment
periods were compared and data were analyzed with a paired t test.
RESULTS: Since July 2013, a total of 92 patients have been enrolled including 45 patients with poorly controlled asthma, 17 children with medical complexity and 30 infants discharged from the NICU. A 46%
reduction in asthma ED visits (65 vs 35, p<0.001, n=35) and a 67% reduction in asthma hospitalizations (21 vs 7, p <0.02, n=35) were observed in asthma patients. A 43% reduction in total ED visits (14 vs 8, p=0.21,
n =12) and a 63% reduction in total hospitalizations (8 vs 3, p=0.16, n=12) were noted in children with medical complexity. Among infants discharged from the NICU, the 30-day readmission rate was 4.5% (n=22).
CONCLUSIONS: We found that it is feasible to develop a multidisciplinary pediatric home visiting program for CSHCN. Our pilot data show a decrease in ED visits and hospitalizations across multiple medical
conditions, suggesting an improvement in health outcomes. Further study is warranted including comparison to a control group, assessment of other patient-centered outcomes and cost-effectiveness of the program.
Filename: 751637
Presenting Author: Danielle P. Wales, MD, MPH
Department/Institution/Address: Pediatrics, Augusta Health, 78 Medical Center Drive, Fishersville, VA, 22939, United States
Phone: 6463727860
Fax:
Title: Immunization Rates of Children Diagnosed with Autism-Spectrum Disorders in New York State: A Pilot Study
Danielle P. Wales1,2, Sara Horstmann1,3, Anthony Malone1,4, Susan L. Hyman5, Judith A. Lucas1, Chandni Vaid1 and Susanna Hill1. 1Pediatrics, Albany Medical Center, Albany, NY; 2Pediatrics, Augusta Health,
Fishersville, VA; 3Pediatrics, Carolinas Health Care/Levine Children's Hospital, Charlotte, NC; 4Developmental-Behavioral Pediatrics, Capital Care Medical Group, Latham, NY and 5Pediatrics, Neurodevelopmental &
Behavioral Pediatrics, University of Rochester, Rochester, NY.
BACKGROUND: Despite being one of the most successful public health achievements in history, many parents have concerns about the safety of vaccines. A common misconception is that vaccines are linked to the
development of Autism-Spectrum Disorders (ASDs). To date, no study has examined whether children with ASDs are up-to-date with recommended immunizations.
OBJECTIVE: This study compares immunization rates of children diagnosed with ASDs from 2 developmental-behavioral practices with immunization rates of New York State children.
DESIGN/METHODS: Records were acquired using the New York State Immunization Information System (NYSIIS). Chi-square analysis was used to compare immunization rates between the control (NYS) and study
(ASD) groups, using the following series:
· 4:3:1:3:3 [4 doses Diphtheria-Tetanus-acellular Pertussis(DTaP): 3 doses Inactivated Polio(IPV): 1 dose Measles-Mumps-Rubella(MMR): 3 doses Haemophilus influenzae type B(Hib): 3 doses Hepatitis B(Hep B)]
· 4:3:1:3:3:1 (previous series plus 1 dose varicella)
· 4:3:1:3:3:1:4 [previous series plus 4 doses of Pneumococcal conjugate vaccine(PCV)].
RESULTS: Out of 12 patients, 11 patients were male. Median age was 31.5 months. For the 4:3:1:3:1 series, the ASD group had a rate of 83.3%, and the NYS group 89.6% (Χ2=0.364, p value=0.546). For the
4:3:1:3:3:1 series, the ASD group had a rate of 75%, and the NYS group 89.6%. (Χ2=1.767, p value=0.184). For the 4:3:1:3:3:1:4 series, the ASD group had a rate of 66.7%, and the NYS group 81.3% (Χ2=1.203, p
value =0.273)
.
CONCLUSIONS: The results of this pilot study suggest that children with ASDs have lower immunization rates compared to the general population, as the number of vaccines in a series increases. These early results
support further study with larger sample sizes. The importance of these findings is underscored by the fact that lower immunization rates are linked with a higher burden of vaccine-preventable diseases.
Filename: 752243
Presenting Author: Caitlin E. Hansen, MD
Department/Institution/Address: Pediatrics, Yale School of Medicine, 333 Cedar Street, PO Box 208064, New Haven, Connecticut, 06510, United States
Phone: 2037854730
Fax: 2037856961
Title: "It All Depends": A Qualitative Study of Parents' Views of Human Papillomavirus (HPV) Vaccine for Their Adolescents At Ages 11-12 Years
Caitlin E. Hansen1, Marisol Credle2,3, Eugene D. Shapiro1,4,5 and Linda M. Niccolai2,3,4. 1Pediatrics, Yale School of Medicine, New Haven, CT; 2Epidemiology of Microbial Diseases, Yale School of Public Health, New
Haven, CT; 3Yale Center for Interdisciplinary Research on AIDS, New Haven, CT; 4Yale Cancer Center, New Haven, CT and 5Investigative Medicine, Yale Graduate School of Arts and Sciences, New Haven, CT.
BACKGROUND: Routine immunization with HPV vaccine is recommended for adolescent girls and boys at 11 or 12 years of age; however, vaccine uptake remains suboptimal. Understanding the reasons why
parents may accept or refuse HPV vaccine for their children at recommended ages is important to improving vaccine coverage in accordance with national guidelines.
OBJECTIVE: To understand the reasons why parents may accept or refuse HPV vaccine for their children at age 11 or 12 years.
DESIGN/METHODS: Semi-structured interviews were conducted with 45 parents whose 10- to 18-year old children receive care at an urban, hospital-based primary care practice. An open-ended interview guide was
used to elicit parents' attitudes towards HPV vaccine, including their opinions about vaccination for their child at different ages (11-12 years vs. 13 years and older). Interviews were audio-recorded and transcribed
verbatim. Qualitative software was used to code and organize transcripts, which were analyzed using thematic analysis. Data collection and analysis continued in an iterative fashion until thematic saturation was
reached.
RESULTS: We identified two major, and somewhat opposing, themes. (1) Positive support for administration of HPV vaccine at ages 11-12 years. Many parents expressed high levels of support for HPV vaccine,
including a majority who agreed with vaccination at 11-12 years. Parents recognized that for prevention of consequences of HPV infection, vaccination of their child early in adolescence was desirable conceptually. (2)
HPV vaccine viewed by parents as a “teen vaccine,” and many coupled need for vaccination with sexual activity. Many parents expressed that in practice, HPV vaccine should be given to adolescents at the onset of
sexual activity, a perception that led to preferences to delay administration of HPV vaccine among certain parents.
CONCLUSIONS: In this population, parents supported administration of HPV vaccine at 11 or 12 years in the abstract, yet many coupled the need for vaccination with whether the adolescents were sexually active.
These apparently contradictory views indicate the need for interventions targeting the benefits of vaccination at the recommended ages. Our findings may be useful in providers' discussions with parents about the
vaccine, as pediatric and adolescent health care providers have the unique opportunity to educate parents and clarify misconceptions about vaccination.
Filename: 750150
Presenting Author: Rotem Elitsur, MD
Department/Institution/Address: 1203 Spruce St, 3 F, Philadelphia, PA, 19107, United States
Phone: 3049721441
Fax:
Title: Obesity Education in the Inpatient Setting: A Needs Assessment
Rotem Elitsur1, Selorm Adzaku1, Katie Tran1, Rita Dohmen1, Geoffrey Bajwa1, Daria Ferro1, Elizabeth Silberholz1, Hannah Neubauer1 and Mario Cruz1. 1Pediatrics, St Christopher's Hospital for Children, Philadelphia,
PA.
BACKGROUND: Obesity is a complex problem. The inpatient setting may provide a unique opportunity to address childhood obesity.Reviews of the ICD 9 codes show that obesity in hospitalized children is under
reported.
OBJECTIVE: We performed a needs assessment of parents,pediatric residents &nursing staff to ascertain the interest in implementing an obesity assessment and intervention program on the inpatient units.
DESIGN/METHODS: Nurses & residents completed surveys assessing their perception of obesity as a problem for the local community,current practices regarding obesity education,interest in participating in obesity
assessment &management on inpatient units &perception of the healthiness of the hospital meals. A sample of parents of overweight/obese children completed surveys assessing their perception of their child's
weight, previous discussions with their pediatrician about weight,interest in discussing obesity prevention strategies during a hospitalization &their perception of the healthiness of hospital meals.
RESULTS: Parental surveys (n = 35) 63% were not concerned about their child's weight.57% have previously discussed weight with their PCP.77% thought that discussing child's weight &nutritional status while
hospitalized would be beneficial.89% thought that the hospital provided meals were healthy.
Nursing surveys (n=21) 86% thought that overweight/obesity was a major problem but only 38% thought that the doctors were addressing the issue.90% believed that healthy lifestyle teachings should be
incorporated while hospitalized.29% believed that hospital-provided meals were healthy.
Resident Surveys (n=34) 100% agreed that overweight &obesity is a major problem however only 79% reported that they encouraged a healthy lifestyle.68% believed that healthy lifestyle teachings should be
incorporated for children while hospitalized.52% felt that obesity education should always be incorporated in discharge planning.Only 9% believed that hospital-provided meals were healthy.
CONCLUSIONS: Most parents of overweight /obese children did not perceive their child to have a weight problem, highlighting the need for better education. The majority of staff &parents reported an interest in
nutrition & lifestyle education for obese children during their hospitalization. Based on our findings,we have implemented a QI project to improve inpatient diagnosis and management of overweight/obesity.
Filename: 753563
Presenting Author: Hilda Kabali, MD
Department/Institution/Address: Pediatrics, 5501 Old York Road, Paley Building 1st Floor, Philadelphia, PA, 19141, United States
Phone: 281-745-3694
Fax:
Title: First Exposure and Use of Mobile Media in Young Children
Hilda Kabali1, Rosemary Nunez-Davis1, Sweta Mohanty1, Jennifer Budacki1, Kristin Leister1, Maria Katrina Tan1, Matilde Irigoyen1 and Robert Bonner1. 1Pediatrics, Einstein Medical Center Philadelphia, Philadelphia,
PA.
BACKGROUND: Smartphones and tablets are the fastest growing technology in human history and mobile devices are becoming the preferred means for children to access media and its content. Little is known about
children's age of initial exposure to mobile media and frequency of use.
OBJECTIVE: To determine age of initial exposure and use of mobile media among young children.
DESIGN/METHODS: We conducted a prospective cross-sectional survey of a convenience sample of parents of children aged 6 months – 4 years in October and November 2014 at a hospital-based pediatric clinic
that serves an urban, low income, minority community. We used a 20-item questionnaire adapted from the “Zero to Eight” Common Sense Media national survey on media use in children. Parents were asked about
types of media devices in their household, children's age at initial exposure to mobile media, frequency of use, types of activities, and if their pediatrician had discussed media use in children.
RESULTS: 370 parents completed the survey;17 refused. Children were evenly distributed across all age groups; 51% were girls; 74% African American, 14% Hispanics; 13% of parents had less than high school
education. Most households had TV sets (97%), tablets (83%), smartphones (77%), and internet access (59%).
How old was your child whe he/she did these activities on a mobile media device?
<1 Year 1 Year 2 Years 3 Years 4 Years
Touched or Scrolled Screen 36%
33%
20%
9%
2%
Called Someone
24%
35%
25%
11%
4%
Watched TV Shows
52%
25%
18%
4%
1%
Played Video Games
12%
26%
36%
18%
7%
Used Apps
15%
26%
36%
17%
7%
Other Activities
32%
25%
26%
15%
3%
Most parents let children play with mobile media while running errands (60%), doing chores around the house (73%), to calm the child (65%), and to put the child to sleep (29%).By 1 year of age, 14% of children were
spending at least one hour per day using mobile media, 26% by age 2, and 38% by age 4. Only 30% of parents reported discussing media use with their child's pediatrician.
CONCLUSIONS: Children are exposed to mobile media devices very early in life, and most children are using them by age two years. A better understanding of the use of mobile media in young children and how it
varies by population groups is critical to help develop educational strategies for both parents and health providers.
Filename: 752250
Presenting Author: Larisa Ivanova, PhD
Department/Institution/Address: Pediatrics, New York Medical College, Vosburgh Pavilion, Valhalla, New Yoek, 10595, United States
Phone: 914-594-3777
Fax:
Title: Rescue of the Mucocutaneous Manifestations in a Mouse Model of Recessive Dystrophic Epidermolysis Bullosa (RDEB) by Human Cord Blood Derived Unrestricted Somatic Stem Cells (USSCs)
Larisa Ivanova1, Ahmed Rashad1, Yanling Liao1 and Mitchell S. Cairo1. 1Pediatrics, New York Medical College, Valhalla, NY.
BACKGROUND: RDEB is a severe inherited skin blistering disease caused by mutations in the COL7A1 gene that encodes type VII collagen (C7), a major component in the anchoring fibrils at the basement
membrane. Allogeneic stem cell transplantation in both experimental animals and human subjects with RDEB resulted in increased C7 deposition and alleviation of the blistering phenotype in some recipients.
However, there was no distinct anchoring fibril formation in the recipient skin and the effective cell types that contribute to the regeneration in RDEB skin remain to be identified. Our previous studies demonstrated that
CB-derived USSCs express C7 and promote epithelialization and wound closure in a murine wound healing model.
OBJECTIVE: To determine the effect of cord blood and cord blood derived USSCs on the Col7a1-/- mice
DESIGN/METHODS: USSCs were injected in the liver of newborn col7a1-/- mice without immunosuppression. The migration and engraftment of USSCs were monitored by bioluminescent imaging (BLI) and
immunocytochemical analyses respectively.
RESULTS: A single intra-hepatic injection of USSCs (0.2 x 106) in newborn RDEB mice arrested the blistering phenotype and significantly enhanced the median survival to 8 days, as compared to 2 days in PBS
injected animals (P<0.0001). A second USSC intra- hepatic injection further elongated the median life span to 16 days (P<0.0001). Remarkably, two mice that received repeated injections survived more than 12
weeks. BLI on the treated RDEB mice and immunocytochemical analyses on dissected tissues demonstrated specific migration of USSCs to the lesions and their engraftment in the dermis and hair follicles of the skin
and gastrointestinal tract. The expression of C7 was detected in the recipient skin and electron microscopy revealed a partial restoration of anchoring fibrils in skin biopsies from the USSC-treated RDEB mice. We also
demonstrated that USSCs treatment induced an infiltration of macrophages with a regenerative “M2” phenotype.
CONCLUSIONS: HUCB- derived USSCs improved the RDEB mucocutaneous manifestations in col7a1-/- mice through multiple mechanisms. This study warrants future clinical investigation of USSCs as a novel
allogeneic stem cell donor source in selected patients with RDEB.
Filename: 755138
Presenting Author: Anu Mallapaty, DO
Department/Institution/Address: Pediatrics, New York Medical College, 19 Skyline Drive, Hawthorne, New York, 10532, United States
Phone: 9145942150
Fax:
Title: Disassociation of T-Cell Recovery with T-Cell Donor Chimerism Following Allogeneic Stem Cell Transplantation (AlloSCT) in Pediatric Recipients
Anu Mallapaty1, Sumith Roy1, Lauren Harrison1, Carmella VanDeVen1, Mark Geyer2, Lee Ann Baxter Lowe3 and Mitchell S. Cairo1. 1Pediatrics, New York Medical College, Valhalla, NY; 2Oncology, Memorial Sloan
Kettering Cancer Center, New York, NY and 3Pathology, Childrens Hospital of Los Angeles, LA, CA.
BACKGROUND: The percent of whole blood donor chimerism following pediatric AlloSCT has a significant impact on the relapse rate after myeloablative conditioning (MAC) (Bader et al, JCO, 2009). Koreth et al
(BBMT, 2014) demonstrated that low T-cell donor chimerism following reduced toxicity conditioning (RTC) and AlloSCT in adults with hematological malignancies is associated with a significant increase in relapse rate
and a corresponding decrease in overall survival. The correlation of T-Cell and NK-cell donor chimerism and normal T and NK cell immune reconstitution following both RTC and MAC AlloSCT in pediatric recipients is
unknown.
OBJECTIVE: To define the correlation of T & NK cell donor chimerism and T & NK immune reconstitution following RTC and MAC.
DESIGN/METHODS: Pediatric allograft recipients were analyzed for probability of acute & chronic GVHD, T and NK immune cell reconstitution and donor chimerism by flow cell sorting and VNTR (Geyer/Cairo et al,
BJH, 2011). Tacrolimus/mycophenolate mofetil was utilized as GVHD prophylaxis (Bhatia/Cairo BBMT, 2010).
RESULTS: Forty five patients, mean age 12 yrs (± 7.3); M: F 25/20; average/poor risk (CIBMTR) 24:21; MAC/RTC 26:19; Donor sources BM: 21 PBSC: 8 UCBT: 16; Related/unrelated: 23:22. Median time to
neutrophil engraftment was 16 days (9-53). Cumulative incident of grade 2-4 acute GVHD was 16.6% (CI95 1.4-47.4) and chronic GVHD 24.1% (CI95, 4.1 – 53.1%). Twenty one patients were included the T-cell
analysis and 25 in the NK analysis given available data. The percent of patients with T-cell & NK cell donor chimerism with ≥ 95% at day 100, 180 and 365 post alloSCT was 88%, 79% and 100% and 94%, 100% and
100%, respectively. The percent T and NK cell recovery at normal levels or day 100, 180, and 365 was 6%, 14%, and 55% and 89%, 89% and 78%, respectively. There was a significant disassociation of T-cell donor
chimerism and normal T-cell recovery at day 100, (P<0.0001) and day 180, (P<0.002) but not so with NK cell donor chimerism and immune recovery.
CONCLUSIONS: This preliminary study suggests that there is a significant delay in T but not NK cell recovery, but robust T and NK donor chimerism following RTC and MAC in pediatric AlloSCT recipients. The
clinical significance of this dissociation is currently under investigation.
Filename: 754708
Presenting Author: Susan M. Braid, DrPH, NNP-BC
Department/Institution/Address: 655 W. Lombard St, W-217, Baltimore, MD, 21201, United States
Phone: 410-706-6004
Fax:
Is Presenting Author a Trainee? Yes, Other - BIRCWH Scholar
Title: The Effect of Antenatal Steroids on Umbilical Cord Blood DNA Methylation in a Preterm Population
Susan M. Braid1, Hector Corrado Bravo2, Kwame Okrah2, Xiumei Hong3, Nana Matoba4 and Xiaobin Wang3. 1University of Maryland Baltimore, Baltimore, MD; 2University of Maryland Institute for Advanced Computer
Studies and Center for Bioinformatics and Computational Biology, College Park, MD; 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD and 4Northwestern University, Feinberg School of Medicine,
Chicago, IL.
BACKGROUND: Antenatal glucocorticoid steroids are routinely administered to women in preterm labor to accelerate fetal lung development. Steroids have been reported to have an impact on both umbilical cord
blood cell composition and DNA methylation (DNAm) differences in brain tissue of exposed and unexposed animals. The independent effect of glucocorticoid steroids on the DNAm of cord blood of exposed infants is
currently unknown.
OBJECTIVE: The objective of this study was to determine if antenatal steroids had an independent effect on DNAm in umbilical cord blood after controlling for the changes in cell composition.
DESIGN/METHODS: We analyzed Infinium Human Methylation 27K array data from the cord blood samples of 60 preterm infants from the Boston Cohort; 19 of these infants were exposed to antenatal steroids. Cord
blood cell composition was estimated using the CpGs described by Houseman et al 2012. We used logistic regression to determine the association between antenatal steroid exposure and gestational age, sex,
granulocyte proportion, and CD4 T cell concentration. We regressed the methylation log-ratio for each CpG site on antenatal steroid exposure, gestational age, and CD4 T cell concentration.
RESULTS: We observed a strong association between antenatal steroid exposure and both early gestational age and CD4 T-cell concentration. When controlling for gestational age and CD4 T cell concentration, only
one CpG site in the promoter region of gene FRA10AC1 within the rare FRA10A folate-sensitive fragile site shows a significant difference in DNAm due to antenatal steroid exposure.
CONCLUSIONS: Increased methylation associated with antenatal steroid exposure in the FRA10A suggests that further investigation should explore the association between hypermethylation and genomic
instabilities associated with depletion of folic acid and the role of antenatal steroids in this mechanism.
Filename: 754645
Presenting Author: Amelie Collins, MD PhD
Department/Institution/Address: Pediatrics and Microbiology & Immunology, Columbia University Medical Center, 701 W 168th Street, HHSC 914, New York, NY, 10032, United States
Phone: 646-872-2099
Fax:
Title: Characterization of Natural Killer Cell Development in the Human Fetus and Newborn
Amelie Collins1 and Steven L. Reiner2. 1Pediatrics, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY and 2Microbiology and Immunology, Columbia University Medical Center, New
York Presbyterian Hospital, New York, NY.
BACKGROUND: Immaturity of the fetal and neonatal immune system is thought to enhance susceptibility to infectious diseases. Natural killer (NK) cells are large granular lymphocytes that comprise an important part
of the innate immune response. In the mouse, the transcription factors T-bet and Eomesodermin (Eomes) seem to control sequential stages of NK cell development. T-bet stabilizes immature NK cells, the
predominant population in the neonate, while post-natal expression of Eomes is required for further maturation to mature NK cells. In humans, fetal and neonatal NK cells also appear to be phenotypically and
functionally immature, however the mechanisms underlying human NK cell development have yet to be fully elucidated.
OBJECTIVE: To determine the molecular checkpoints that control natural killer cell development in the human fetus and newborn.
DESIGN/METHODS: We have generated a novel collection of fetal tissues from products of conception of 14 to 22 weeks with no known anomalies that have been electively terminated. Fetal organs are collected in
the operating room at the time of termination and are processed to yield single cell suspensions of mononuclear cells that are cryopreserved for further phenotypic characterization by flow cytometry and functional
assays including cytokine production and cytotoxicity.
RESULTS: Our preliminary results suggest that NK cells in human fetal liver are delayed in their development compared to NK cells in other fetal organs and in newborn umbilical cord blood. In contrast to the mouse,
expression of both T-bet and Eomes is seen in NK cells in the human fetus, suggesting that the immaturity of human fetal/neonatal NK cells is not regulated at the level of Eomes expression. We have found two NK
cell subsets with reciprocal levels of T-bet and Eomes expression (T-betint Eomeshi and Tbethi Eomesint) which are differentially distributed in liver compared to other fetal organs. Characterization of these subsets by
expression of the cell surface markers CD94 and CD16 suggests that the Tbetint Eomeshi population is a precursor to the Tbethi Eomesint population. Work is ongoing to characterize the functional capabilities of these
human fetal NK cell subsets.
CONCLUSIONS: Human fetal NK cells express the transcription factors T-bet and Eomes and an immature population is enriched in the fetal liver. Characterizing NK cell development in the human fetus and newborn
will lead to a better understanding of the unique susceptibility of these populations to infection.
Filename: 753788
Presenting Author: Anita M. Ware, DO
Department/Institution/Address: Pediatrics, Metropolitan Hospital Center, 1901 First Avenue, New York, NY, 10029, United States
Phone: 1-914-263-2760
Fax:
Title: Efffect of Gestational Immaturity on T-Cell Sub-Types and CD+71 Erythroid Cells
Anita M. Ware1,2, Carl V. Hamby3, Neetu Godhwani4 and Edmund F. La Gamma2. 1Pediatrics, Metropolitan Hospital Center, New York, NY; 2The Regional NICU, Maria Fareri Children's Hospital, New York Medical
College, Valhalla, NY; 3Microbiology and Immunology, New York Medical College, Vahalla, NY and 4Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY.
BACKGROUND: Throughout gestation, fetuses transition from immune tolerance to immune defense functions. While studies have looked at the effect of prematurity on immune cells, it is still unclear which
developmental changes among cell populations are significant determinants of immune capability.
OBJECTIVE: Enumerate CD4, CD8, NK, T regulatory, Th17 and CD71+ cell subsets to examine dysregulation of cells related to gestational age (GA) and/or events related to delivery.
DESIGN/METHODS: Samples are grouped based on the gestational age of the fetus at time of delivery. Use flow cytometry to assess quantitative differences in cell subsets.
RESULTS:
Group Group
Group
Group
Cell Population
<27wk 28-31wk 32-35wk >36wk
T Regulatory Cells (median %)
5.8
6.5
5.7
4.5
CD4 (average %)
20
43
70
63
CD8 (average %)
10
8
26
29
Total T cells (average %)
50
55
44
28
Th17 (% of CD4)
0.22
0.48
0.43
CD71+ (median %)
26
9
25
T regulatory cells: Median percentages are not significantly different between groups. T Cell subsets: Percentages of CD4+ & CD8+ increased with GA while total T cell percentages declined approaching term.
Average levels of Th17 cells are low across all age groups. CD71+ cells: Percentage of CD71+ cells ranged from 6-63% with median of 23%; no age-related trends in levels of Th17 and CD71+ cells were identified. In
samples analyzed to date, CD71 depleted cells appear to have increased production of TNFα & IL-6 compared to undepleted cells
CONCLUSIONS: We find unchanged levels of T-regulatory cells throughout gestation & increases in percentages of CD4+ and CD8+ cells with gestational age. High levels of CD71+ cells are seen throughout
gestation that may suppress inflammatory responses. To further validate these preliminary observations we anticipate needing to enroll 15-20 subjects in each gestational age category.
Filename: 752924
Presenting Author: Kristin M. Scheible, MD
Department/Institution/Address: Pediatrics, University of Rochester, 601 Elmwood Avenue, Box 651, Rochester, NY, 14642, United States
Phone: 585-275-7919
Fax: 585-461-3614
Title: Perinatal T Cell Dysregulation in Preterm Infants Is Associated With Pulmonary Morbidity and Continues Through Infancy
Jason Emo1, Wang Hongyue2, Heidie Huyck1, Sara Misra1, Ravi Misra1, David J. Topham3, Rita M. Ryan4, Ann M. Reynolds5, Thomas Mariani1, Gloria S. Pryhuber1 and Kristin M. Scheible1. 1Pediatrics, University of
Rochester, Rochester, NY; 2Biostatistics and Computational Biology, University of Rochester, Rochester, NY; 3Center for Vaccine Biology and Immunology, University of Rochester, Rochester, NY; 4Pediatrics, Medical
University of South Carolina, Charleston, SC and 5Pediatrics, Women and Children's Hospital of Buffalo, Buffalo, NY.
BACKGROUND: Perinatal systemic inflammation is associated with the development of chronic lung disease in preterm (PT) infants. It is unclear if pro-inflammatory, differentiated T cells detected in early neonatal
period are associated with pulmonary morbidity and if they are a sustained population contributing to chronic disease.
OBJECTIVE: To test the hypothesis that a perinatal inflammatory T cell bias correlates with the need for mechanical ventilation (MV) in preterm infants and this phenotype is carried through infancy.
DESIGN/METHODS: Using samples and clinical data collected at the Universities of Rochester and Buffalo, cytokine-producing and regulatory T cell (Treg, CD4+CD127dimFoxP3+) populations were quantified by
flow cytometry following in vitro stimulation of mononuclear cells isolated from infants (n=88, 23-40 weeks GA) from cord blood (CB), at time of NICU discharge, and at 12 months (12m) CGA.
RESULTS: PT requiring MV during their NICU course had higher frequency of pro-inflammatory TNFα+CD4+ T cells in CB (p=0.02). Regression analysis suggests that elevations in TNFα+CD4+ T cells were due in
part to degree of prematurity and the need for MV inversely correlated with CGA (p=<0.0001). In contrast, Treg cells were elevated at birth in PT requiring MV despite controlling for GA (p<0.01). At discharge and
12m, a strong correlation between CD4+ and CD8+ TNFα+ percentages (p<0.0001), higher in PT born at younger CGA, was detected. Neither discharge nor 12m TNFα+ T cells were associated with need for MV
when controlling for GA. Tregs remained elevated at discharge in younger PT, but were not associated with MV in NICU at this timepoint.
CONCLUSIONS: T cells from PT infants at lower CGA are biased towards a pro-inflammatory TNFα response at birth, in spite of higher frequencies of Tregs, a bias that continues into infancy. Inflammatory T cells
may predispose PT infants to immune dysregulation through their development in the first year of life. Elevated Tregs at birth is a potential predictor of pulmonary morbidity in the NICU, and may reflect failure of an
important immune regulatory mechanism. Funding: U01 HL101813 (Prematurity and Respiratory Outcomes Program), 1K12HD068373-01 (Translational Molecular Pediatrics).
Abstract Number:
Filename: 750577
Presenting Author:
Department/Institution/Address:
Phone:
Fax:
Presenting Author E-mail:
Is Presenting Author a Trainee? Not Yet Indicated
Title:
Filename: 753291
Presenting Author: Janet E. Orrock, MD
Department/Institution/Address: Pediatric Residency Program, Children's National Health Systems, 111 Michigan Avenue, NW, Washington, DC, United States
Phone: 202-476-5225
Fax:
Title: Association of Brain Injury and Neonatal Cytokine Response During Therapeutic Hypothermia (TH) in Newborns With Hypoxic Ischemic Encephalopathy (HIE)
Janet E. Orrock1, Karuna Panchapakesan2, Gilbert Vezina3,6, Kari Harris4, Taeun Chang4,6, Susan Knoblach2,6 and An N. Massaro5,6. 1Pediatric Residency Program, Children's National Health Systems, Washington,
DC; 2Center for Genetic Medicine Research, Children's Research Institute, Washington, DC; 3Diagnositic Imaging and Radiology, Children's National Health Systems, Washington, DC; 4Neurology, Children's National
Health Systems, Washington, DC; 5Neonatology, Children's National Health Systems, Washington, DC and 6The George Washington University School of Medicine, Washington, DC.
BACKGROUND: HIE is an important cause of newborn brain injury. Pro-inflammatory cytokines have been proposed as mediators of brain injury via neuroinflammatory pathways triggered by hypoxia-ischemia..
Limited data are available on cytokine profiles in HIE newborns treated with TH.
OBJECTIVE: To determine whether cytokine profiles can differentiate HIE patients with death or severe brain injury from survivors with mild/no injury.
DESIGN/METHODS: Serum specimens from HIE newborns were collected at 24 and 72 hours of TH. MRIs performed after TH were scored according to Barkovich (AJNR 1998). Electrochemiluminescence
technology (Meso Scale Discovery, Rockville, MD) was used to measure inflammatory cytokines: IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-13,TNF-α, IFN-γ. Infants were categorized by outcome: Grp 1= death, basal
ganglia injury score ≥ 3 or watershed score ≥ 4 vs Grp 0= survivors with mild/no MRI injury. Differences in cytokine levels between outcome groups were compared using Wilcoxin rank-sum tests.
RESULTS: Thirty-two HIE newborns (Grp 0: n=19, Grp 1: n=13) with mean±SD GA 38.8±1.4 wks, BW 3.2±0.8 Kg and 47% male were included. Baseline characteristics were similar between groups except that Grp 1
had lower 5-min Apgar score (median 2, IQR 2 vs 4, IQR 4; p=0.016) and more infants with severe encephalopathy (46% vs 0%, p=0.002). All cytokines were elevated in Grp 1 vs Grp 0 at 24 hours except for IL-4,
TNF-α, and IFN-γ, while only IL-6 remained significantly elevated in Grp 1 vs Grp 0 at 72 hours.
CONCLUSIONS: Inflammatory cytokines IL-1B, IL-2, IL-6, IL-8, IL-10, and IL-13 are elevated at 24 hours of TH in HIE newborns with poor outcomes. All cytokine levels decreased at 72 hours, although IL-6 continued
to differentiate outcome groups. These data suggest that neuroinflammatory cytokine response in the first 24 hours of TH may identify infants in need of additional neuroprotective interventions.
Filename: 751021
Presenting Author: Bushra Afzal, MBBS
Department/Institution/Address: Pediatrics(Neonatal-Perinatal Medicine), The Women and Children Hospital of Buffalo, 219 Bryant Street, Buffalo,NY, 14222, United States
Phone: (716)878-7662
Fax:
Title: Hypothermia and Vasoreactivity in Asphyxiated Lambs
Bushra Afzal1, Justin Helman1, Sylvia Gugino1, Praveen Kumar Chandrasekharan1, Jayasree Nair1 and Satyan Lakshminrusimha1. 1Pediatrics, University at Buffalo,The State University of New York, Buffalo, NY.
BACKGROUND: Moderate hypothermia (33.5°C) improves survival without disability in hypoxic ischemic encephalopathy (HIE). Shankaran et al reported 7% and 14% in-hospital mortality with whole body
hypothermia at 33.5 and 32°C respectively for 72h (PAS 2014: 2823.5). Neonates with HIE are at risk for pulmonary hypertension (PPHN) and systemic hypotension.
OBJECTIVE: We aimed to determine the effect of cooling and rewarming on isolated pulmonary (PA) and carotid arterial (CA) tone in asphyxiated lambs and to measure the basal and NO-induced cGMP production in
PA and CA smooth muscle cells (PASMC and CASMC) at 37, 33.5 and 32°C.
DESIGN/METHODS: 15 term lambs were asphyxiated by cord occlusion for 10min. PA and CA were isolated in standard vessel chambers with bath temperature randomized to 37, 33.5 and 32°C. Change in tone due
to cooling and rewarming was recorded. Smooth muscle cells were incubated with sildenafil (basal) or NO donor+sildenafil (stimulated) for 3h at 37, 33.5 and 32°C and cGMP was measured.
RESULTS: Cooling from 37 to 32°C decreased basal tone in PA and CA. Rewarming from 32 to 37°C increased basal tone in PA but not in CA.
Cyclic GMP levels in PASMC and CASMC increased at 32°C. NO increased cGMP at all temperatures.
Table1. cGMP levels (pmol/mg protein) in smooth muscle cells
† p <0.05 cf. 33.5°C; ∆ p<0.05 cf. 37°C; *p<0.05 cf. basal
PASMC
CASMC
ANOVA
37°C
33.5°C
32°C
37°C
33.5°C
32°C
Basal
0.39±0.07
0.42±0.09
1.41±0.45†∆
0.43±0.14
0.55±0.12
1.47±0.46†∆
0.04
NO Stimulated
4.69±1.08*
4.62±0.89*
6±1.7*
5.93 ±1.16*
8.74±1.68*
5.30±1.18*
0.37
CONCLUSIONS: Cooling to 32°C relaxed CA and increased cGMP in CASMC. Rewarming from 32 to 37°C increased PA tone and reduced cGMP in PA. These changes were less pronounced at 33.5°C. Deep
hypothermia(32°C) may increase the risk of systemic hypotension and could exacerbate PPHN during the rewarming phase in HIE.
Filename: 754125
Presenting Author: Melanie Leong
Department/Institution/Address: Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, 245 N. 15th Street, New College Building, MD 1029, Philadelphia, PA,
Phone: 215-762-7515
Fax: 215-762-7960
Title: Effect of Hypothermia on High Affinity Ca2+ ATPase Activity in the Cerebral Cortex of Newborn Piglets Following Hypoxia
Melanie Leong1, Waseem Akhter1, Nicholas Obiri1, Andy Wang1 and Maria Delivoria-Papadopoulos1. 1Department of Pediatrics, Drexel Univeristy and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Hypothermia (HT) has emerged as a therapeutic intervention that may be neuroprotective in infants with acute hypoxic ischemic (HI) encephalopathy. Hypothermia has been shown to ameliorate
neuronal injury and to improve the neurodevelopmental outcomes of survivors with hypoxic ischemic encephalopathy. Nuclear calcium signals control nuclear functions including regulation of transcription factors, cell
cycle regulation, and gene transcription. High affinity Ca2+-ATPase regulates nuclear Ca2+ influx. We have previously shown that high affinity Ca2+-ATPase activity increases in the cerebral cortex following hypoxia in
normothermic piglets.
OBJECTIVE: The present study tests the hypothesis that the hypoxia-induced increased affinity of high-affinity Ca2+-ATPase is attenuated by the induction of hypothermia in the cerebral cortex of newborn piglets.
DESIGN/METHODS: Newborn piglets were divided into the groups: normoxic (Nx, n=3), hypoxic (Hx, n=3), and hypoxic treated with hypothermia (Hx+HT, n=3). Hypoxia was induced by decreasing FiO2 to 0.07 for 1
hr. Hypoxia was documented by levels of ATP and phosphocreatine (PCr). The hypothermic group was cooled to 33°C for 4 hrs. The activity of high affinity Ca2+-ATPase was determined in a 1-mL assay medium
containing 20 mM HEPES, 100 mM KCl, 250 mM MgCl2, 100 µM EGTA, 95 µM CaCl2, 1 mM ouabain, 1 mM ATP, and 150 µg nuclear protein. The reaction was carried out at 37°C for 30 min.
RESULTS: ATP (µmoles/g brain) was 4.40±0.40 in Nx, 1.57±0.29 in Hx, and 5.66±0.27 in Hx+HT. PCr (µmoles/g brain) was 3.5±0.2 in Nx, 1.3±0.3 in Hx, and 2.59±1.57 in Hx+HT. The high affinity Ca2+-ATPase
activity was 245±74 nmol Pi/mg protein/h in Nx, 426±95 nmol Pi/mg protein/h in Hx, and 355 nmol Pi/mg protein/h in the Hx+HT group. The data show that hypothermia resulted in a 17% reduction in hypoxia induced
high affinity Ca2+-ATPase activity.
CONCLUSIONS: We conclude that hypoxia induced high affinity Ca2+-ATPase activity was attenuated by hypothermia following hypoxia in the brain of newborn piglets. Mechanisms underlying hypothermic
neuroprotection continue to be unclear, but are multifactorial in nature and are likely related to the suppression of excitotoxity, oxidative stress, inflammation, intracellular signaling, and programmed cell death. We
suggest that a combination of hypothermia and inhibitors of apoptosis will augment neuroprotection following hypoxia.
Filename: 750918
Presenting Author: Shadi Malaeb
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Cerebral Energy Failure after Hypoxia-Ischemia in Newborn Piglets: Protection by Hypothermia
Shadi Malaeb1, Siba A. Islam1, Nicholas Obiri1, Juan Ballesteros1 and Maria Delivoria-Papadopoulos1. 1Dept. of Pediatrics, Drexel University and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: It is known that during energy failure and reperfusion injury there is a deterioration of brain metabolism by increasing the oxidative stress. Studies have shown that hypothermia functions by lowering
the oxygen and glucose consumption by neural cell and by protecting integrity of the cell membrane and inhibiting enzyme activity that leads to apoptosis or death.
OBJECTIVE: To test the hypothesis that induction of hypothermia following hypoxia-ischemia (HI) attenuates secondary energy failure following HI in newborn piglets.
DESIGN/METHODS: Ventilated newborn piglets were exposed to hypoxic FiO2 0.07 for 1 hr then returned to FiO2 0.21 to restore O2 and blood pressure. Piglets were studied acutely following HI (HI-acute), or were
either cooled to 33°C or maintained at normal body temperatures for 4 hrs (HI-HT-4Hr, HI-4Hr respectivley). Normoxic (Nx) piglets served as controls. Cerebral energy status was determined by measuring high
energy phosphate levels per gram of tissue spectrophotometrically using a coupled enzyme assay. The ATP concentration was calculated from the increase in absorbance of NADPH at 340 nm for the 20-min period
after the addition of hexokinase to a cerebral tissue homogenate mixture containing NADP and glucose-6-phosphate. PCr will be measured after the addition of creatinine kinase and ADP.
RESULTS: ATP levels (µmole/g brain, M±SEM) were 4.77 ± 0.21 in Nx (n=7), 1.32 ± 0.21 in HI-acute (n=6 ; p<0.05 vs Nx), 2.48 ± 0.46 in HI-4Hr (n=4; p<0.05 vs HI-acute; p<0.05 vs Nx) and 5.66 ± 0.15 in HI-HT-4Hr
(n=3 ; p<0.05 vs HI-acute and HI-4Hr; p=NS vs Nx). PCr levels (µmole/g brain, M±SEM) were 3.37 ± 0.09 in Nx (n=2), 0.79 ±0.18 in HI-acute (n=5; p<0.05 vs Nx), 3.11± 0.33 in HI-4Hr (n=3; p<0.05 vs HI-acute) and
2.31±0.25 in HI-HT-4Hr (n=3;p<0.05 vs HI-acute, p=NS vs HI-4 Hr). Cerebral ATP levels were reduced by 72% acutely following hypoxia, but levels were restored to levels comparable to those seen in normoxia
when hypothermia was induced after HI. Cerebral PCr levels were reduced by 75% following hypoxia, but were only partially reduced with hypothermia.
CONCLUSIONS: Hypothermia maintains cerebral energy status following hypoxia. We propose that mitochondrial preservation in the brain to be a mechanism for neuroprotection by hypothermia. We suggest that
combination of hypothermia and other neuroprotective agents that improve mitochondrial function to augment neuroprotection by hypothermia.
Filename: 751451
Presenting Author: Shadi Malaeb
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Effect of Concurrent Inhibition of Nitric Oxide Synthase and Hypothermia on Free Radical Injury after Hypoxia-Ischemia in the Newborn Piglet Brain
Shadi Malaeb1, Taylor Wheaton1, Amit Jain1, Siba A. Islam1 and Maria Delivoria-Papadopoulos1. 1Dept. of Pediatrics, Drexel University and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Hypothermia (HT) is used as a therapeutic intervention for acute hypoxic ischemic (HI) encephalopathy in newborns but outcome of survivors remains guarded. We have previously shown free
radical damage to cell membranes during recovery from acute HI in the piglet brain. We have also shown that the mechanism of HI-induced activation of the apoptotic cascade is mediated by neuronal nitirc oxide
synthase (nNOS).
OBJECTIVE: The present study tests the hypothesis that concurrent administration of nNOS inhibitor with hypothermia after HI is associated with further attenuation of free radical cerebral injury compared to
hypothermia alone in piglets.
DESIGN/METHODS: Newborn piglets were exposed to HI [FiO2 0.07 for 1 hr and hypotension (40% decrease in systolic BP)], then returned to FiO2 of 0.21 to restore O2 and BP. Piglets were studied acutely
following HI, or received saline or a specific inhibitor of nNOS (7-Nitroindazole monosodium salt; 7-NINA 1 mg/kg i.v.) immediately after HI and then either cooled to 33°C or maintained at nomral temperatures for 4
hrs (HI-NT4Hr, HI-HT, and HI-HT-7NINA groups, respectively). Normoxic normothermic (Nx-NT) and hypothermic (Nx-HT) piglets served as controls. Lipid peroxidation was determined spectrophotometrically as
conjugated dienes (CD) in the membrane fraction.
RESULTS: Conjugated dienes (pmole/g protein; M±SEM) were 12.5±0.3 in Nx-NT (N=2) and 12.9±0.6 in Nx-HT piglets (N=4; p=NS vs Nx-NT). CD increased to 19.3±0.7 acutley following HI (N=3, ANOVA, F=19.6,
p<0.05 vs Nx-NT) and decreased to 16.6±0.8 in HI-NT4Hr piglets at 4 hrs post HI (n=3; p=NS vs acute HI; p<0.05 vs Nx-NT). In contrast, at 4 hours post-HI, CD decreased to 13.2±0.3 in HI-HT piglets (n=2; p<0.05
vs HI-NT4Hr; p=NS vs Nx-HT), and to 11.5±0.2 in HI-HT piglets treated with 7-NINA after HI (n=2; p<0.05 vs HI-NT4Hr; p=NS vs HI-HT, Nx-HT). The data show 31% reduction in lipid peroxidation in piglets with
7-NINA and HT after HI compared to 20% reduction with HT alone.
CONCLUSIONS: We conclude that concurrent inhibition of neuronal nitric oxide synthase by 7-NINA and induction of hypothermia after HI reduces cerebral free radical injury compared to hypothermia alone. We
propose that mechanisms of neuroprotection by HT involve reduction of nNOS derived NO production. We suggest that nitric oxide synthase inhibition may augment neuroprotection achieved by hypothermia.
Filename: 753064
Presenting Author: Kunal Chadha, MD
Department/Institution/Address: Pediatric Emergency Medicine, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY, 14222, United States
Phone: 716-228-2672
Fax:
Title: Limiting Unnecessary Cervical Spine Computed Tomography in Pediatric Trauma Evaluation
Kunal Chadha1, Jennifer Argentieri1, Scott Bouton1 and Brian Wrotniak1. 1Pediatric Emergency Medicine, Women and Children's Hospital of Buffalo, Buffalo, NY.
BACKGROUND: The NEXUS study provides criteria to determine patients >1 year of age who are at low risk for c-spine injury and thus do not require imaging. However, if a child is determined to need imaging to
evaluate c-spine injury, the two most common imaging techniques used are plain radiographs and computed tomography (CT). Both of these imaging modalities are limited in their ability to identify ligamentous injury
and thus controversy exists between the balance of radiation exposure and the risk of missing a significant injury. While the frequency of CT scan use is increasing, the Society of Pediatric Radiology has campaigned
to “image gently” and reduce radiation doses in children
OBJECTIVE: To evaluate whether there was a decrease in the unnecessary use of pediatric cervical spine CT imaging by comparing the total number/rate of c-spine CT use in trauma patients, before and after the
implementation of the Trauma Committee c-spine evaluation guidelines. Follow up with neurosurgery was evaluated to identify patients who had c-spine injuries not found during initial evaluation in the emergency
department
DESIGN/METHODS: Chart review of patients presenting to Women and Children's Hospital of Buffalo (WCHOB) with level 1 or 2 trauma activations from 1/1/11 to 12/31/11 and 4/1/12 to 4/1/13. Trauma activation
level was defined according to criteria set by the WCHOB/Trauma Committee that takes into account the mechanism of injury and severity of derangement. The Pediatric Emergency Medicine (PEM) department
participated in a didactic lecture highlighting the Trauma Committee recommendations and current body of literature on 1/5/12. PEM physicians were encouraged to follow the guidelines when evaluating trauma
patients and use c-spine CT imaging only for abnormal/inadequate plain films or GCS <9/intubated patients
RESULTS: 332 cases of trauma activation were evaluated after the Trauma Committee recommendations. The implementation of a stepwise approach yielded a decrease in c-spine CT imaging from 29.41% to
6.12%. During neurosurgery follow up, 30 patients were seen. 8 received repeat imaging (3 CT, 2 MRI, 3 Flex/Ex) and none were found to have newly identified c-spine injuries
CONCLUSIONS: A stepwise algorithm incorporated in the evaluation of the c-spine during trauma activations at WCHOB, was shown to significantly reduce the frequency of CT imaging without compromising the
identification of c-spine injury during initial emergency department evaluation
Filename: 755410
Presenting Author: Stephen Alerhand, MD
Department/Institution/Address: 1245 Park Avenue, Apt 19A, New York, NY, 10128, United States
Phone: 732-580-2211
Fax:
Title: Effects of Ultrasound as an Initial Imaging Modality on Complication Rates in Children with Suspected Appendicitis
Stephen Alerhand1 and Ee Tay2,3. 1Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 3Emergency
Medicine Ultrasound, Icahn School of Medicine at Mount Sinai, New York, NY and 4Pediatric Emergency Medicine, Jacobi Medical Center, Bronx, NY.
BACKGROUND: Computed tomography (CT) has traditionally been used as the initial diagnostic modality for detecting appendicitis. Recent studies favor the use of ultrasound (US) in children with suspected
appendicitis due to its diagnostic accuracy, safety, and associated shorter emergency department (ED) length of stay. CT scans performed after non-diagnostic US studies may increase ED management time and
may potentially contribute to progression of disease.
OBJECTIVE: This study evaluates whether performance of CT scan after non-diagnostic US increases complication rates in children with appendicitis.
DESIGN/METHODS: We conducted a retrospective chart review of children ≤ 17 years old for the past 10 years who were diagnosed with appendicitis in an urban pediatric ED. Patients with known appendix
perforation, transfers from outside hospitals for appendicitis management, and patients with appendicitis on studies but no appendectomy performed were excluded. Imaging modalities (US, CT, or US and CT), study
results, surgical and pathology reports, and length of stay from ED triage to appendectomy incision time were collected. Related medical visits, radiology studies, and additional procedures within 6 months of operation
were also collected. The primary outcome measure was appendiceal complication rate. This was defined as presence of perforation or gangrenous appendix on surgical or pathology report, as well as unscheduled
medical visits, radiology studies, or procedures performed within 6 months after appendectomy.
RESULTS: 502 charts were reviewed, 209 subjects were eligible. Complication rates for US, US followed by CT, and CT were 22.04%, 31.67%, and 27.27%, respectively. The odds ratios of complications in
comparison to the CT group were 0.75 (95% CI = 0.35-1.59, p =0.46) for US and 1.24 (95% CI = 0.53-2.92; p=0.63) for US followed by CT. The length of stay from ED triage to appendectomy incision for US, US
followed by CT, and CT were 518 ± 285 minutes, 923 ± 506 minutes, and 566 ± 337 minutes, respectively. A one-way ANOVA test showed that US followed by CT was more likely to increase length of stay compared
to using US or CT alone (p<0.01). There was no significant difference between the US and CT groups.
CONCLUSIONS: CT scans performed after non-diagnostic US studies did not increase complication rates despite significant increases in ED length of stay. US appears to be a safe first-line imaging modality in
children with suspected appendicitis.
Filename: 752291
Presenting Author: Andrew T. Rizzo, DO
Department/Institution/Address: 25 Bailey Rd., Millburn, NJ, 07041, United States
Phone: 9739535230
Fax:
Title: Finding Comfort in Different Diagnostic Modalities for Children With Suspected Appendicitis
Andrew T. Rizzo1, Viviana C. Forti1, Camille N. Immanuel1 and Michael Gorn1. 1Division of Pediatric Emergency Medicine, St. Joseph's Regional Hospital Medical Center, Paterson, NJ.
BACKGROUND: Ultrasound (US) and computed tomography (CT) are used to evaluate children with suspected appendicitis. Magnetic resonance imaging (MRI) has recently been studied as an alternative. There are
published data examining tolerance of children undergoing MRI that supports its use without sedation. There are no trials that compare all 3 modalities in terms of child's comfort and preference.
OBJECTIVE: To analyze comfort level and modality preference of US, CT or MRI in children with suspected appendicitis.
DESIGN/METHODS: Children <18 yrs of age were asked to complete a standardized survey. Patients were recruited while being enrolled into a related prospective study evaluating the use of sedation-free abdominal
MRI compared to US and CT in children with suspected appendicitis. The child's parent/guardian administered the survey and aided in its completion. The survey was available in English and Spanish.
RESULTS: 104 patients qualified for enrollment, 84(82%) were enrolled. 5 of 104(4.8%) patients did not tolerate MRI exam, 15(14%) were eliminated for unrelated reasons. 66 of 84(79%) completed the survey, 9 of
264(3.4%) answers were missing. The mean patient age was 12 years (SD±3), 31(47%) were male, 25(38%) had appendicitis, and 9(14%) had experienced prior MRI exams. Overall, 6(9%) patients rated MRI as
"very uncomfortable" or "uncomfortable". When comparing modalities, patients ranked MRI as "more comfortable" than CT/US in 30(45%) cases, "same" in 14(21%) cases, and "less" in 20(30%) cases. No statistical
difference between comfort rating and age, sex or clinical outcome was found(all p>0.05). Overall, MRI was selected as best modality by 20/66(30%), CT 14/47(30%), and US 25/54(46%) patients who had the exam.
CONCLUSIONS: Sedation-free abdominal MRI is generally well tolerated by children undergoing evaluation for appendicitis. MRI is at least as comfortable as either CT or US. MRI and CT rank similarly, and US is the
most preferred modality regardless of patient age, sex or clinical outcome.
Filename: 755228
Presenting Author: Yue J. Lin
Department/Institution/Address: Department of Molecular and Cell Biology, University of Connecticut, 91 North Eagleville Road, Unit 3125, Storrs, CT, 06269, United States
Phone: 860-486-4329
Fax:
Title: Assessing Childhood Obesity Risk Through Parental Diet and Location of Residence
Yue J. Lin1, Christine H. Mulvey2 and Sharon R. Smith2. 1Department of Molecular and Cell Biology, University of Connecticut, Storrs, CT and 2Department of Emergency Medicine, Connecticut Children's Medical
Center, Hartford, CT.
BACKGROUND: Emergency Departments (ED) can screen for behavior risks of childhood obesity as part of its primary care mission. Previous work has shown that a simple liking survey can screen for behaviors
associated with levels of adiposity. Additional information can be gleaned by having parent reports independent of children self-report.
OBJECTIVE: To examine the relationship between parental and child report of food liking and residential location on child adiposity.
DESIGN/METHODS: A prospective study enrolled children age 5-17 in the ED. Children and their parents were asked to complete a food and activity liking survey. A Healthy Behavior Index (HBI) score was
calculated for both child and parent as a weighted average of their respective liking scores, with scores weighted based on recommendations for healthy weight. HBI scores range from +100 to -100, with more positive
scores indicative of healthy behaviors and more negative scores indicative of unhealthy behaviors. Body mass index (BMI) and waist circumference (WC) percentiles were collected along with demographic
information.
RESULTS: Enrolled were 552 children (mean age=11±4 years), including 285 (52%) female, 231 (42% Caucasian, 291 (53%) on public insurance, and 156 (28%) living in Hartford. 89 (16%) children were overweight
and 117 (21%) were obese. Children (HBI =-22.2±0.7) reported less healthy scores than the parent (HBI =0.9±0.8). Children in higher BMI and WC percentiles had lower child HBI and parent HBI scores than those in
the healthy ranges. Child HBI showed stronger associations to adiposity in females than in males. Parent HBI scores showed stronger associations to child adiposity than the child HBI score. Patients living in the city
of Hartford had HBI scores below average (Child = -24.4±1.2, Parent = -3.5±1.4). Subjects who identified themselves as African American (-24.4±1.7/-3.5±1.8), Latino (-23.0±1.2/-3.51±1.2), or covered by public
insurance (-23.6±1.0/-1.51±1.1) also had HBI scores below average, with child/parent HBI scores respectively.
CONCLUSIONS: These results demonstrate that obesity risk may be predicted using food liking surveys. Parental preference is a more accurate predictor of child adiposity than child preference. The results also
demonstrate impact of residential location on dietary habits. Participants from the city of Hartford, currently classified as a food desert, showed worse dietary behavior in both the child and parent than areas outside of
Hartford.
Filename: 756145
Presenting Author: Sneha Patel, MS2
Department/Institution/Address: Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07052, United States
Phone: 9733240105
Fax: 9739728276
Title: Pain Assessment and Management of Children Presenting To Pediatric ED with Long Bone Fractures
Noah P. Kondamudi1 and Sneha Patel2. 1Pediatrics, Rutgers New Jersey Medical School, Newark, NJ and 2Rutgers New Jersey Medical School, Newark, NJ.
BACKGROUND: The American Academy of Pediatrics and the American Pain Society have issued a joint statement recommending that pain be recognized and treated more aggressively in children. Expressed or
not, acute fractures cause significant pain that prompts timely and appropriate analgesic therapy. Painful experience in children can have long term effects. There have been recent reports of overuse of narcotic
analgesics while other reports of under recognition and treatment of pain in children
OBJECTIVE: The objective of this study is to determine the timeliness of pain assessment and analgesic therapy for children presenting with fractures to the emergency department.
DESIGN/METHODS: This is a retrospective review of 120 randomly selected medical records of children presenting with acute fractures during 2013, to a level 1 inner city trauma center with a dedicated Pediatric
Emergency department (PED, 22K visits). Demographic variables along with times to pain assessment and analgesic administration were collected. Statistical analysis was done using SPSS.
RESULTS: Of the 120 patients, 71% were males (n=85), and 52% were greater than 10 years old. The most frequent fracture was that of distal radius (46%, n=55). There was no pain assessment at triage in 34%
(n=29), and no pain score in 32% (n=38) of patients. Similarly, there was no ED pain assessment in 73% (n=88) of patients. Analgesic medication in PED was given to 60% (n=72) of patients and the most frequent
analgesic was Ibuprofen (28%, n=35) followed by morphine in 22% (n=27). Reassessment of pain was documented in only 8% of patients (n=10). Discharge pain medications were given to 34% (n=41). The mean
duration to get analgesic medication after ED triage was 93 minutes (Range 1-454, SD=94). Only 46% (n=33) of patients received analgesic within one hour of triage. There was significant association between
performance of pain assessment in triage and giving analgesic therapy (p=0.003). No association detected between giving analgesia with age, gender, or type of fracture.
CONCLUSIONS: Pain assessment at triage or ED occurred in only a third of patients which may have contributed to 40% of children not receiving analgesia. There is a wide variation with the timeliness of
administration of pain medications with less than half getting their analgesia within one hour after triage evaluation. There is a need for continued education about prompt pain management for children presenting to
ED with long bone fractures.
Filename: 755657
Presenting Author: Mohsen Saidinejad, MD, MBA, FAAP
Department/Institution/Address: Emergency Medicine and Trauma Center, Children's National Health System, 111 Michigan Avenue, NW, Washington, DC, 20010, United States
Phone: 202-476-4177
Fax: 202-476-3573
Title: Leadership Rounding in the Emergency Department (ED): An Opportunity for Real-Time Patient Experience Feedback
Mohsen Saidinejad1, Sephora N. Morrison1, Sabah F. Iqbal1, Joanna S. Cohen1, Kristen A. Breslin1, Shilpa J. Patel1 and James M. Chamberlain1. 1Emergency Medicine and Trauma Center, Children's National Health
System, Washington, DC.
BACKGROUND: Feedback is important to optimize patient experience during an ED visit. Current method of post-visit patient satisfaction survey by mail limits actionable interventions and service recovery.
OBJECTIVE: To determine the usefulness of leadership rounding for real-time patient experience feedback during an ED visit.
DESIGN/METHODS: We conducted a cross-sectional study of patients with ED length of stay > 2 hours during our 12 month period (Nov 1, 2013-Oct 31, 2014). A leadership rounding tool consisting of 5 validated
components of rounding (greeting and introduction by providers, informing patients about delays in care, recognizing excellent care by a staff member, overall patient experience , and improvement opportunity) was
designed. Rounds were conducted by either attending physicians or nursing supervisors without prior warning. We compare our results with standard post-visit surveys conducted during the same period.
RESULTS: Overall, the proportion of those reporting a positive experience was significantly higher in our leadership rounds than in our current post-visit patient satisfaction survey (92% versus 61%, p<0.001). This
was also true for each component of rounding.
Leadership rounding (%) Satisfaction survey (%) Absolute % difference (95% CI with continuity correction)
n
566
2877
Greeting & Introduction performed 537 (94.9)
2528 (87.9)
7 (4.1-9.1)
Informed about delays
545 (96.3)
2005 (69.7)
26.6 (24.0-28.8)
Specific staff recognized
127 (22.4)
91 (3.2)
19.3 (15.9—23.0)
Opportunity for improvement
151 (26.7)
239 (8.3)
18.4 (14.7-22.4)
Overall negative experience
3 (0.5)
107 (3.7)
3.2 (1.9-4.1)
Overall positive experience
521 (92.1)
2286 (79.5)
12.6 (9.6-15.1)
Real-time intervention
54 (9.5)
N/A
Leadership rounding generated an actionable feedback resulting in real-time intervention in 9.5% of the participants. Length of ED stay affected patient experience (4.1 +/- 2.6 hours for those with negative and neutral
experience versus 2.7 +/- 1.2 hours for those with positive experience, p<0.001) as reported with leadership rounding.
CONCLUSIONS: Leadership rounding reveals a more positive patient experience compared to post-visit satisfaction surveys. Further studies are needed to determine the causes of this difference and to validate of
our findings over other environments and larger sample size.
Filename: 750403
Presenting Author: Sara B. Cortes, MD
Department/Institution/Address: Emergency Medicine, New York Methodist Hospital, 506 6th Street, Brooklyn, NY, 11209, United States
Phone: 305-582-8899
Fax:
Title: Correlating Bedside Lung Ultrasound with Tachypnea in Bronchiolitis: Preliminary Data from the B-PLUS Study
Sara B. Cortes1 and Sharon Yellin1. 1Emergency Medicine, New York Methodist Hospital, Brooklyn, NY.
BACKGROUND: Acute bronchiolitis is a commonly occurring respiratory tract infection in infants up to 2 years old. Currently, the diagnosis is based on clinical signs, with multiple studies showing no benefit to the
routine use of chest radiography. The American Academy of Pediatrics (AAP) 2006 Clinical Practice Guidelines recommends that the diagnosis be made on history and physical examination (5), with recommendation
against routine chest radiography. Chest xray findings do not correlate with the severity of disease. We are interested in exploring the ways lung sonography (LUS) can assist clinicians in determining the severity of
disease and potentially predict those patients that either have other pathology present (ie pneumonia) or will require admission.
OBJECTIVE: To evaluate the relationship between increased compact B-lines on bedside lung ultrasound (BLUS) and clinical signs of more severe disease in children with bronchiolitis
DESIGN/METHODS: We currently have 47 patients from an on-going cross-sectional study. Patients less than 2 years old with clinically diagnosed acute bronchiolitis per defined guidelines from the American
Academy of Pediatrics, excluding patients with chronic illnesses including congenital heart disease, asthma, cystic fibrosis, or any cardiothoracic surgery were enrolled in the Emergency Department (ED). Pediatric
providers recorded respiratory rate for each patient. BLUS was performed by ED physician, in 6 fields (anterior, axillary, and posterior bilaterally.) B-lines were measured in one rib space for each field, and recorded
categorized into mild, moderate, severe (<3, 3-10, >10)
RESULTS: Patients with mild (n=21) and moderate (n=17) tachypnea had no difference in number of lung fields with <3 B-lines, mean 4.86, 5.06 (SD 1.65, 1.34), respectively.
Patients with severe tachypnea (n=9), average 23 bpm over maximum for age, had a mean of 1.78 lung field with 3-10 B-lines (SD 1.86) and 3.67 lung fields with <3 B-lines (SD 1.41).
CONCLUSIONS: Increased compact b-lines on BLUS shows correlation with higher respiratory rates over maximum for age. Ongoing research is needed to further evaluate this correlation and use of BLUS in the
clinical course of bronchiolitis.
Filename: 750632
Presenting Author: Margaret A. Lafferty, MD
Department/Institution/Address: Nemours A. I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE - DELAWARE, 19803, United States
Phone: 3024295861
Fax:
Title: The Impact of Trained Pediatric Specialists on Pediatric Transport to a Pediatric Tertiary Care Facility
Margaret A. Lafferty1, Margarita Lorch1 and James Hertzog1. 1Nemours A.I. DuPont Hospital for Children, Wilmington, DE.
BACKGROUND: Inter-facility transport of pediatric patients is a common, though challenging, practice. Many are subsequently discharged home from the pediatric emergency department (PED), or shortly after
admission to the hospital. Evaluation by a physician with specialized pediatric training at a community hospital may decrease the number of unnecessary pediatric patient transfers.
OBJECTIVE: To determine if evaluation by a pediatrician in a community hospital emergency department decreases the number of patients transferred to a children's hospital and then subsequently discharged.
DESIGN/METHODS: We reviewed charts from patients transferred from a single referring hospital with available electronic medical record data 1 year before and 1 year after the hospital implemented a program to
have pediatricians evaluate pediatric patients in their Emergency Department. We looked at common chief complaints with an a priori high likelihood of discharge from the PED including breathing problem, asthma,
respiratory distress, pneumonia, fever, and seizure. Rates of admission and discharge for these two time periods were compared using X2.
RESULTS: During the studied 2 year period, 455 patients were transferred from the study hospital to our PED: 181 before the implementation of the pediatric evaluation program, 274 after. The most common chief
complaints were respiratory complaints (23%), seizure (9%), abdominal pain (7%), and fever (4%). Among the 6 a priori chief complaints of interest with a high likelihood of discharge from the PED, there was a
statistically significant increase in discharge rate (9% vs 29%) from the PED after the implementation of a pediatric evaluation at the referring hospital (p=0.027).
CONCLUSIONS: Contrary to our hypothesis, more patients were discharged from the PED following transfer despite evaluation at the referring hospital by a pediatrician, concurrent with an increase in the total
number of transports from the referring facility. Given the challenges of pediatric transport, it is crucial to transport patients only when necessary. Ongoing investigation is needed to determine why this change may
occur.
Filename: 750605
Presenting Author: Kimberly E. McMahon, MD
Department/Institution/Address: Department of Critical Care Medicine, Nemours/Alfred I duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, United States
Phone: 4846800262
Fax:
Title: Rapid Transfer to the Pediatric Intensive Care Unit after Admission from the Emergency Department: Role of the Pediatric Early Warning Score
Kimberly E. McMahon1, Erica L. Del Grippo1, Christopher J. Plymire1 and Andrew D. DePiero1. 1Nemours/Alfred I duPont Hospital for Children, Wilmington, DE.
BACKGROUND: Admission decisions in the emergency department (ED) can be challenging. Admitting a patient to a general inpatient unit who then quickly requires transfer to an intensive care unit (ICU) generates
stress and safety concerns for staff, patient and family.
OBJECTIVE: Our study sought to identify predictors at the time of admission from the ED of patients likely to require rapid transfer to the ICU. Pediatric Early Warning Scores (PEWS) rate patients on a scale of 0-13
and can predict patients at risk for clinical deterioration. We hypothesized that PEWS obtained prior to admission could be predictive of need for transfer, and that PEWS would increase in patients requiring ICU
transfer.
DESIGN/METHODS: We retrospectively reviewed charts of patients requiring transfer to the ICU within 10 hours of admission from the ED at a single pediatric tertiary care center from 3/1/09 to 10/1/13. These 73
case patients were then matched by age and diagnosis with 73 control patients who were admitted from the ED and never required ICU admission. PEWS were calculated prior to ED departure, on admission to the
floor and, for cases, at time of ICU transfer. Scores were compared between cases and controls and between each time point.
RESULTS: The PEWS for case patients in the ED were higher than those for controls (p=0.026). Case patients in the ED had a median PEWS of 2 with interquartile range (IQR) of 4 while controls had a median of 0
and IQR of 3. PEWS on admission remained higher for cases than controls (median 3/IQR 4 versus median 1/IQR 3). On transfer to the ICU, PEWS for case patients had increased to a median of 4 with IQR of 5.
CONCLUSIONS: Our review demonstrates that as expected, for patients requiring ICU transfer within hours of admission from the ED, PEWS increased from the ED to admission and at time of ICU transfer.
Interestingly, at the time of ICU transfer, median PEWS was only 4, which is typically the lowest level that would predict increased risk for a critical event. When comparing cases to controls, PEWS were higher at
each time point. This review demonstrates that elevated PEWS do correlate with need for ICU transfer, however, the level of the score is less than might be expected. With patients requiring rapid transfer to the ICU
having a median PEWS of only 2 in the ED, it is likely not practical to use this as a tool to request ICU evaluation while still in the ED.
Filename: 750123
Presenting Author: Melanie A. Weller, MD
Department/Institution/Address: Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822-60-5, United States
Phone: 570-372-0536
Fax:
Title: Reducing Repeat Head Computed Tomography for Pediatric Trauma Patients
Melanie A. Weller1, Alfred P. Kennedy1, Carol A. Hanson1 and Christopher P. Coppola1. 1Geisinger Medical Center, Danville, PA.
BACKGROUND: Trauma is one of the most common reasons a child requires emergent medical attention, and for many children trauma evaluation includes computed tomography(CT). Regionalization of trauma care
with interhospital transfer often results in multiple CT scans, which increases exposure to ionizing radiation, thus increasing a child's future cancer risk. This study evaluates the ability of trauma protocol procedural
changes to reduce the incidence of repeat CT.
OBJECTIVE: Evaluate effect of pediatric surgeon presence on use of head computed tomography (CT) in pediatric trauma.
DESIGN/METHODS: Retrospective review of children age zero to 14-years-old presenting to a pediatric level II trauma center as a pediatric trauma alert from January 1, 2010 to June 30, 2012. Children were
transferred from another facility or presented directly. Inclusion criteria were children who received at least one head CT. Trauma registry and electronic medical record were reviewed for mechanism of injury and
rationale for any CT, including repeating CT done at a transferring facility. CT of all body regions was reviewed. Use of head CT as well as compliance to hospital policy on use of CT in trauma victims was analyzed.
Data from two distinct time periods was evaluated as prior to or after implementation of pediatric trauma surgeon presence at every pediatric trauma, starting July 1, 2011. Additional system changes in the time period
studied are implementation of radiographic image sharing software (lifeIMAGE, Newton, MA), on May 22, 2012, as well as new protocols for severe and mild pediatric brain injury.
RESULTS: A total of 288 children met the inclusion criteria of pediatric trauma alert, and had at least one head CT scan at transferring facility or pediatric trauma center. Pediatric surgeon presence at trauma
evaluation was associated with a decrease in rate of repeat head CT from 59% to 19% (p<0.001). Repeat head CT had a trend of increased frequency in younger children; 0-4-years-old: 59%, 5-9-years-old: 24%, and
10-14-years-old: 17% (p=0.08).
CONCLUSIONS: Pediatric trauma patients are at increased risk for unnecessary and or repeated CT scans. Attending pediatric trauma surgeon supervision at all pediatric traumas was associated with reduced rate of
repeat head CT scan.
Filename: 753004
Presenting Author: Margaret E. Samuels-Kalow, MD MPhil
Department/Institution/Address: 4742 Pine Street, Philadelphia, PA, 19143, United States
Phone: 646-267-9866
Fax:
Title: Parent Preferences for the Pediatric Emergency Department Discharge Process
Margaret E. Samuels-Kalow1, Alyssa R. Smith2, Emily Hardy1, Karin Rhodes3 and Cynthia Mollen1. 1Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; 2Boston Combined Residency Program
for Pediatrics, Boston, MA and 3Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
BACKGROUND: Emergency department (ED) discharge is a time of significant vulnerability for families as important information is communicated in a time-limited, distraction-filled environment. Limited health literacy
may put parents at increased risk of incomplete comprehension, but the relationship between parental communication needs at the time of discharge and health literacy has not been well defined.
OBJECTIVE: The goal of this study was to characterize parental perceptions of needs and preferences regarding ED discharge, and how those vary by health literacy.
DESIGN/METHODS: We conducted an in-depth interview study. Parents were included if they were the legal guardian of a child <=11 who was treated for an asthma exacerbation in the ED with planed discharge to
home. Parents completed the Parental Health Literacy Activities Test (PHLAT), an in-person interview by a trained interviewer, and a brief survey including data on income, education and insurance status. We used
purposive sampling to balance the sample between high and low literacy and conducted interviews until thematic saturation was reached in both literacy groups. The interview guide included domains of prior ED
experiences, barriers, and facilitators to learning. Interviews were audiotaped, transcribed, coded independently by two study team members, and analyzed using a modified grounded theory approach.
RESULTS: 31 patients were interviewed. 15 (48%) were low literacy, 26 (85%) were Black or African-American and 25 (81%) had state insurance. In both literacy groups, parents identified a desire for more
information, and a need for increased use of lay language, verbal instruction and demonstration. Childcare and distraction were identified as barriers for both groups. High literacy parents requested a dosing schedule.
Low literacy parents reported a desire for a single point person for information communication and concerns around inconsistencies in advice and instruction between providers and between materials. Several
parents, in both literacy groups, described feeling judged and uncomfortable asking questions.
CONCLUSIONS: Parents of children with asthma identified actionable improvements to the ED discharge process. Low literacy parents may benefit from increased attention to consistency across different sources of
information. Improving parent comfort with asking questions and admitting confusion will be important to improve discharge communication with all families.
Filename: 755036
Presenting Author: Shiv D. Gandhi, BS
Department/Institution/Address: 615 South 11th Street, Apartment 3, Philadelphia, PA, United States
Phone: 8607566022
Fax:
Is Presenting Author a Trainee? Yes, Other - Graduate Student
Title: Determining Which Children Need ECGs in the Emergency Department
Shiv D. Gandhi1, Jesse Sturm1, Danielle Federico1, Renee Silvis1, Jill Popp1, Harris Leopold1 and Sharon R. Smith1. 1Pediatrics, Connecticut Children's Medical Center, Hartford, CT.
BACKGROUND: Electrocardiograms (ECG) are frequently done in the pediatric emergency department (PED) but significant cardiac problems are not common.
OBJECTIVE: to develop a decision rule for ordering ECGs in the PED.
DESIGN/METHODS: A retrospective study evaluated all children with an ECG over a two-year period in an urban PED. Children birth to 18 years who had an ECG were included. Past medical and family histories
were abstracted on a standardized data sheet, along with demographic characteristics, chief complaint, vital signs including room air oxygen saturation (above or below 95%) and ED and cardiology interpretations.
Pediatric literature was referenced to determine age appropriate normal ranges for all vital signs, scored as low, normal or high. A recursive petitioning model was used to develop a decision rule abnormal ECG.
RESULTS: 890 children had ECGs and 880 had final interpretations recorded in chart. They were 55% girls, 46% Caucasian, 28% Hispanic, 16% African American, and had a mean age 11.7 years. Congenital
cardiac history was noted in 9.5% of patients, acquired cardiac history in 2.5%, and significant cardiovascular family history <1%. 76% had normal ECGs. Common abnormal ECGs consisted of: SVT/tachycardia
(32%), bradycardia (25.8%), prolonged QTc (18.3%), LVH (12%). The decision rule includes 1) acquired or congenital cardiac past medical history 2) heart rate presentation and 3) respiratory rate. According to the
recursive partitioning model, abnormal ECGs corresponded to children with cardiac past medical histories or those with no cardiac PMH but with a high age adjusted HR and/or RR on presentation.
CONCLUSIONS: Children with cardiac medical histories or those with high HR and/or RR are likely to have abnormal ECGs. Presenting histories of syncope or chest did not correlate with abnormalities. Most children
who present with chest pain and normal vital signs will not have abnormal ECGs.
Filename: 755762
Presenting Author: Mary Emborsky, DO
Department/Institution/Address: 219 Bryant Street, Buffalo, NY, 14222, United States
Phone: 7168787109
Fax:
Title: Comparing Focused Assessment with Sonography for Trauma (FAST) with Computed Tomography (CT) in Detecting Intra Abdominal Injury (IAI) in Pediatric Patients Presenting to the Emergency
Department (ED) with Blunt Abdominal Trauma (BAT)
Mary Emborsky1 and Brian Wrotniak1. 1Pediatrics, Women and Children's Hospital of Buffalo, Buffalo, NY.
BACKGROUND: Abdominal CT is the gold standard tool for the evaluation of children with suspected IAI. There are recent concerns regarding the radiation exposure from CT and the increase in life time risk of
developing cancer.1 A FAST exam uses ultrasound to rapidly screen for free fluid, a sign of IAI. A FAST exam is quick, inexpensive, noninvasive and does not required ionizing radiation. FAST has become standard of
care in adult abdominal trauma; the sensitivity is close to 95%. 2
OBJECTIVE: Determine the sensitivity of a FAST exam performed by PEM physicians as compared to CT in detecting IAI in children presenting to our ED with BAT.
DESIGN/METHODS: Children under 16 years old, with history consistent with BAT requiring a CT of the abdomen to evaluate for an IAI, were enrolled. A FAST exam was performed by a credentialed PEM physician
before the CT. A positive FAST exam was defined as detection of free fluid and or organ injury. A positive CT scan was defined as organ injury and or free fluid. The FAST exam findings were compared to the CT
scan results. The CT results were divided into types of organs inured and if hemoperitoneum was present.
RESULTS: Of the 124 patients were enrolled, 27 (20%) had positive CT scans. Our FAST exam was positive in 10 (37%) of these patients. Of the 28 patients with a positive CT scan, 8 (28%) had organ injury and
hemoperitoneum: 3 liver lacerations, 3 splenic lacerations, 1 small bowel perforation, and 1 kidney laceration. Our FAST exam was positive on 6 (75%) of these patients. The FAST exam was less sensitive on injuries
with none or only physiologic free fluid seen on CT as compared to more significant injuries with more free fluid.
CONCLUSIONS: FAST exams in children less than 16 years old, performed by PEM physicians are moderately sensitive in detecting free fluid on patients with IAI after blunt abdominal trauma. This result is similar to
other studies, where blunt abdominal trauma causing bleeding in the abdomen from high grade liver and splenic lacerations, are more likely to also have a positive FAST exam. Our results are consistent with the
preliminary research examining validity of the FAST in kids.3
Filename: 756454
Presenting Author: Pranavi Vemuri, MS2
Phone: 7324293180
Fax:
Title: Does Time To Treatment Influence Hospitalizations Among Children Presenting to the ED with Acute Asthma Exacerbation?
Pranavi Vemuri1, Anjali Mitra1, Daniel Krich1 and Noah Kondamudi1. 1Pediatrics, Rutgers New Jersey Medical School, Newark, NJ.
BACKGROUND: The NHLBI guidelines for asthma recommend initiation of immediate treatment of children presenting with symptoms suggestive of acute asthma exacerbation. However, due to many operational
constraints in ED, it is not uncommon to have some delay before therapy is initiated. There is some evidence that early initiation of steroid therapy results in reduced rate of hospitalization.
OBJECTIVE: The objective of this study is to identify any relationship of time with initiation of therapy with hospitalization. Secondary objectives are to identify if key elements of asthma history such as asthma type are
documented and if patients are discharged with an asthma action plan
DESIGN/METHODS: A retrospective chart review of randomly selected patients (147) with acute asthma exacerbation presenting to an academic Pediatric ED (22K visits annually) was performed. There were 114
treat and release patients and 33 admissions. Data related to demographics, key historical features, time of initiation of nebulization and steroid therapy and discharge with asthma action plan was collected. Statistical
analysis was performed using SPSS.
RESULTS: Asthma type based on severity was documented in 39% of patients (n=58), but peak flow rate was performed in only 13% of patients. A total of 29% patients received their first nebulization within 20
minutes (n=42) and steroids within one hour in 29% (n=42). The mean duration to first nebulization was 52 minutes and mean time for initiation of steroid for admitted patients was 97.4 minutes (SD=117.2) and 'treat
and release' patients was 73.34 (SD=55.9).
Admitted (%) (n=33) Treat and Release (%) (n=114)
1st nebulization within 20 minutes
30
28
1st nebulization within 20 minutes
67
68
1st steroid within 1 hour
45
46
1st steroid after 1 hour
55
54
p
0.04
NS
CONCLUSIONS: Majority of patients had delays in initiation of therapy with nebulization and steroids. Delays in nebulization were significantly associated with hospitalization. Poor documentation in part, may have
played a role limiting the generalizability of these findings. There is a need to improve documentation and provision of timely care for children with acute asthma exacerbation.
Filename: 756471
Presenting Author: Anjali Mitra, MS2
Phone: 9736874479
Fax:
Title: Are We Doing Too Many Tests for Children Presenting to the in the Emergency Department With Acute Asthma Exacerbation?
Anjali Mitra1, Pranavi Vemuri1 and Noah Kondamudi1. 1Pediatrics, Rutgers New Jersey Medical School, Newark, NJ.
BACKGROUND: The NHLBI guidelines for asthma state 'Most patients who have an asthma exacerbation do not require any initial laboratory studies', yet it is common place to perform an array of lab tests in children
presenting with acute asthma to the emergency department (ED). The 'Choosing Wisely' campaign further discourages unnecessary lab testing that does not offer value to patient care.
OBJECTIVE: Our objective is to determine the extent of lab or radiology work up performed on patients diagnosed with acute asthma exacerbation to the ED and when performed, if the materially altered any
management plan
DESIGN/METHODS: A retrospective chart review of randomly selected patients (140) presenting to an academic Pediatric ED (22K visits annually) was performed. Data related to lab tests and length of ED stay was
collected. Value of the test was assigned if it changed clinical management of the patient. Statistical analysis was performed using SPSS.
RESULTS: A total of 53 (38%) patients received 209 tests some form of radiological or laboratory testing for 1.49 tests per patient. The most common lab test done was CBC in 24% of patients (n=33) and chest x-ray
was performed in 25% (n=35) of patients. Rapid antigen testing for RSV and Influenza was done in 15 patients (11%). There was no change in management based on any test results in the treat and release group.
The most common abnormality was hypokalemia in 9 patients all of whom were hospitalized. There was significant association between testing and ED length of stay >3 hours (0.0001). When analysis confined to
treat and release patients, the significant association with testing remained (p=0.03).
CONCLUSIONS: Performance of tests for treat and release patients with acute asthma exacerbation do not provide value and increases ED length of stay. There is a need to educate faculty to minimize testing for
non-admitted patients with asthma exacerbation.
Filename: 754522
Presenting Author: Bryan N. Swenson
Department/Institution/Address: Molecular and Cell Biology, University of Connecticut, 91 North Eagleville Road, Unit 3125, Storrs, CT, 06269, United States
Phone: +18604864329
Fax:
Title: The Initial Effects of the Patient Protection and Affordable Care Act (PPACA) on Pediatric Emergency Departments (PEDs)
Bryan N. Swenson1, Sharon R. Smith2 and Jesse J. Sturm2. 1Molecular and Cell Biology, University of Connecticut, Storrs, CT and 2Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT.
BACKGROUND: On January 1, 2014, the Patient Protection and Affordable Care Act (PPACA) became effective for all new public and privately subsidized health insurance plans. All states were required to raise the
Medicaid eligibility for children to 133% of the federal poverty line (FPL). Subsidized private plans were available to people between 100% and 400% of the FPL. Preliminary data provided by the Heritage Foundation
show nationwide private insurance declined modestly and nationwide public insurance increased modestly since inception. The PPACA mandates incentivize patients to seek primary and preventive care to avoid
unnecessary ED visits.
OBJECTIVE: To evaluate the effect of the PPACA on pediatric emergency department (PED) visits in terms of patient insurance composition and total PED visits.
DESIGN/METHODS: The insurance coverage composition of patients presenting to the PED was assessed with the Pediatric Health Information System (PHIS) that includes data from over 40 children's hospitals
nationwide. Quarter 1 (Q1) of 2013 (pre-PPACA) was compared to Q1 of 2014 (post-PPACA) by percentage of patient population presenting with private insurance, Medicaid and self-pay methods.
RESULTS: Overall 1,085,699 patient visits to PEDs were evaluated from January 1, 2013 to March 31, 2013 and from January 1, 2014 to March 31, 2014. From the pre-PPACA period to the post-PPACA period,
overall PED visits in PHIS hospitals decreased 9% from 568,666 to 517,033. From the pre to post period, patients presenting to PEDs with Medicaid, private insurance and self-pay methods decreased from 60.26% to
58.16% (p<0.0001), decreased from 24.1% to 23.38% (p<0.0001) and increased from 4.8% to 5.7% (p<0.0001), respectively.
CONCLUSIONS: This study found a decrease in private insurance coverage in PEDs in the post-PPACA period. This is consistent with national enrollment data from Q1 showing employers dropping employee private
health coverage. Despite an increase in overall national Medicaid enrollment, this study of PED visits shows a decrease in overall patient PED volume and Medicaid patient composition. This may reflect patients being
redirected to other sites of primary care, a stated objective of the PPACA.
Filename: 756150
Presenting Author: Oluwakemi Badaki-Makun, MD
Department/Institution/Address: Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, Maryland, 21287, United States
Phone: 410-955-6146
Fax: United States
Title: Non-Pathogens and Positive Blood Cultures in Sickle Cell Patients Presenting to the Emergency Department with Fever
Oluwakemi Badaki-Makun1, Angela Ellison2, Brittany Oliver3, Mark Nimmer4, Nihal Ali3, Katie Eisenbrown4, James Chamberlain3 and David C. Brousseau4. 1Pediatrics, Johns Hopkins University School of Medicine,
Baltimore, MD; 2Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 3Pediatrics, George Washington University School of Medicine, Washington, DC and 4Pediatrics, Medical
College of Wisconsin, Milwaukee, WI.
BACKGROUND: Blood culture contamination rates in Emergency Departments (EDs) are up to 11% of all cultures drawn, potentially leading to unnecessary interventions. Current benchmarks recommend decreasing
contamination rates to no more than 2 to 3%. Febrile children with Sickle Cell Disease (SCD) are at increased risk of bacteremia due to compromised immune function and therefore routinely have blood cultures
drawn in the ED.
OBJECTIVE: To determine blood culture contamination rates for febrile SCD patients evaluated in the ED.
DESIGN/METHODS: We conducted a retrospective, cross-sectional study of SCD patients aged 3 months to 21 years presenting with fever ≥ 38.5ºC to 3 tertiary care pediatric EDs from 2008 to 2012. All charts for
SCD patients with fever at home or in the ED were reviewed for number of blood cultures, total positive cultures and organisms isolated. Organisms known to be non-pathogens (contaminants) were determined a
priori based on published literature. Results are presented as percentages, with 95% confidence intervals (CI).
RESULTS: Of 4294 qualifying ED visits of febrile SCD patients, 3921 (91.3%) had a blood culture drawn. Positive cultures were present in 116/3921 (2.96%, 95% CI 2.43%-3.49%) samples. Non-pathogen organisms
were identified in 76/3921 (1.94%, 95% CI 1.51% to 2.37%) of all cultures collected and 76/116 (65.5%, 95% CI 56.87% to 74.17%) of all positive cultures. True pathogen organisms were identified in 40/3921 (1.02%,
95% CI 0.71% to 1.33%) of all cultures. The most commonly identified organisms are depicted below.
CONCLUSIONS: Overall blood culture contamination rates were within accepted benchmarks at 1.94%, however, non-pathogens accounted for almost 66% of all positive cultures in this large sample of febrile SCD
patients. Further study is required to delineate factors associated with true bacteremia in order to appropriately identify those SCD patients most at risk.
Filename: 754070
Presenting Author: Kirishanth Perinpanathan, MD
Department/Institution/Address: 240 Willoughby Street, Apt 17 F, Brooklyn, NY, 11201, United States
Phone: 347-884-3690
Fax:
Is Presenting Author a Trainee? Yes, Other - Graduate awaiting residency
Title: Effect of Childhood Obesity on Emergency Department Resource Utilization in an Inner City Community Hospital
Kirishanth Perinpanathan1, Noah Kondamudi1, Majo Joseph1 and Upile Nawartne1. 1The Brooklyn Hospital Center, Brooklyn, NY.
BACKGROUND: Childhood obesity and the associated co-morbidities have emerged as one of the major healthcare epidemics. There is only limited knowledge on the effect of childhood obesity in emergency room
settings. We hypothesize that obese children would have higher resource utilization during an Emergency Department (ED) visit compared to normal weight children.
OBJECTIVE: Our study aims to determine the difference in resource utilization between obese and normal weight children.
DESIGN/METHODS: This is a retrospective review of medical records of patients, aged 2 to 17 years, evaluated in a Pediatric ED of a community hospital in 2013. A total of 200 patient charts were reviewed. 100
obese children (BMI ≥95th percentile for age and sex) were randomly identified along with 100 age and gender matched controls (BMI of 10-85th percentile for age and sex) that had an ED visit during the same time
period. In addition to demographic data, information pertaining to chief complaint, previous ED visits, presence of co-morbidities, laboratory and radiological studies performed, consults requested, prescriptions given
and subspecialty referrals was collected. Data was analyzed using chi-square tests and student t-tests.
RESULTS: Comparison of resource utilization between the two groups are presented in the table below:
Variables
Obese Normal p-value
Presence of Co-morbidities
Laboratory tests performed
Radiological tests performed
Prescriptions given
Consults requested
Subspecialty referrals given
20
18
16
39
6
20
13
14
19
31
13
14
0.18
0.44
0.58
0.24
0.09
0.26
There was no documentation of 'obesity' in any chart. Counseling for weight loss was documented in only one patient. There was no significant association with type of health insurance and resource utilization
between the two groups.
CONCLUSIONS: ED resource utilization in our setting was similar between obese and normal weight children. Our results are similar to those of Fleming-Dutra et al. (2013) and Trasande et al. (2009) which showed
little or no difference in acute care costs between obese and normal weight children. There is a need to enhance documentation of obesity in the medical record, and to initiate appropriate counseling and referral from
the emergency department. In addition to the limitations inherent to a retrospective study, the sample size is not high powered and the results are not generalizable as findings emanate from a single institution.
Filename: 754591
Presenting Author: Nitin Ron, MD
Department/Institution/Address: Pediatrics, New York Methodist Hospital, 506 6th St, Brooklyn, NY, 11222, United States
Phone: 3474460360
Fax:
Title: Development of a Reliable Physiologic Model for Prediction of High Altitude Illness
Nitin Ron1, Abhinav Parikh1, Mazin Alhamdani1, Barbara Gatton1, Nayaab Khawar1, Pramod Narula1 and Lawrence Melniker1. 1Pediatrics, New York Methodist Hospital, Brooklyn, NY.
BACKGROUND: High altitude illness affects many hikers and climbers in the mountains, including children, teenagers and young adults. Paradoxically teenagers and young adults are known to have higher incidence
of this condition. High altitude illness is caused by the reduction in air pressure and oxygen levels in altitudes greater than 2500m. The syndrome includes acute mountain sickness (AMS), high altitude cerebral edema
(HACE) and high altitude pulmonary edema (HAPE). High-altitude illness can be used as a model to study the pathophysiological process of hypoxia in an otherwise healthy cohort.
OBJECTIVE: The aim of our expedition was to study human physiology prior to ascent, during ascent, and at very high and extreme altitudes using various investigative techniques in order to develop a reliable
prediction model for high altitude illness.
DESIGN/METHODS: These studies were performed at sea level and at low, high and extreme altitude in the Himalayas, including Mt. Everest.Investigative techniques such as optic nerve sheath diameter (ONSD)
measurement using portable ultrasound and neurocognitive testing for assessment of potential high altitude cerebral edema (HACE); pulmonary function tests (PFTs) for assessment of potential high altitude
pulmonary edema (HAPE) and sonographic skin testing (SST) were used to assess fluid shift in people exposed to very high and extreme altitude to provide a comprehensive evaluation of human physiologic changes
at high altitude.
RESULTS: We were able to obtain measurements at five different altitudes– sea level, 1500m, 3500m, 3800m, and 5200m. Each component included measurements of ONSD, neurocognitive testing, PFTs, and skin
thickness. Investigators and subjects were able to perform all tasks and collect data three times at each altitude. Large amount of data were obtained at high and extreme altitudes using the equipment and methods
described in this study. High level of significance was noted for some of the tests including neurocognitive testing (p=0.0025), ONSD (P=0.006) and SST (p=0.0025).
CONCLUSIONS: Using the information obtained from this study we will be able to develop a reliable physiologic predictive model for high altitude illness and better understand human physiology at high and extreme
mountain conditions.
Filename: 753690
Presenting Author: Elaine Lin
Department/Institution/Address: Pediatric Emergency Medicine, Boston Childrens Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States
Phone: 6467054144
Fax:
Presenting Author E-mail:
Title: Patient Outcome Feedback for the PEM Provider: Are We Meeting the Need?
Elaine Lin, Michael P. Goldman1 and Martin V. Pusic2. 1Pediatric Emergency Medicine, Boston Childrens Hospital, Boston, MA and 2Pediatric Emergency Medicine, New York-Presbyterian Hospital Columbia
University Medical Center, New York, NY.
BACKGROUND: Countless decisions are made by providers in the Pediatric Emergency Room, many of which occur without awareness of their consequences. Outcome-based feedback entails getting patient
outcomes to the provider after care is rendered. This feedback is central to the educational and quality improvement processes within a Pediatric Emergency Medicine (PEM) community. Prior authors have proposed
that a lack of such feedback may contribute to diagnostic error, negative patient outcomes and failure of the individual provider to improve practice.
However, ideal feedback can be difficult to execute within the current constraints of time, information technology and tight budgets. Additionally, demonstrating practice change as a result of such an intervention poses
methodological challenges.
OBJECTIVE: Our ultimate goal is to design, implement and evaluate a novel feedback mechanism that results in provider practice improvement. Before embarking on this endeavor, we aimed to identify what types of
information PEM providers desire.
DESIGN/METHODS: We conducted a structured focus group of 20 PEM faculty at a single institution. Participants were asked to consider the following prompt: “in an ideal world, without barriers to obtaining high
quality feedback, list examples of feedback you would want with respect to your clinical practice.” Specific examples were organized into categories through a “KJ” affinity exercise. An online survey was implemented
for ”member-checking.”
RESULTS: 20 PEM providers participated in the focus group. 58 examples of feedback were organized into 11 categories. The categories were: Outpatient Followup Plans, Outpatient Diagnosis Revealed, Pending
Diagnostic Studies, Bounce Back Patients, Surprises from Inpatient Diagnosis, Surprises from Patient Acuity, Cosmetics, Reports, Peer Practice Comparison, Patient Satisfaction and Medical Education.
17 PEM providers completed the survey. 7 of the 11 categories averaged a score of 4 or 5 “strong or most interest." The highest rated categories included “Surprises from Inpatient Diagnosis” (e.g. my admission for
fever was KD - 4.71) and “Surprises from Patient Acuity” (e.g. 'X' of my admissions require escalation of care - 4.59). The lowest rated category was “Peer Practice Comparison” (e.g. my use of testing compared with
peers - 3.65).
CONCLUSIONS: There are several aspects of a PEM provider's clinical practice that are desired as feedback. In a big data world, it seems we could deliver improved data flows back to the PEM provider.
Filename: 750574
Presenting Author: Folashade Farri, MD, MPH
Department/Institution/Address: PEDIATRICS, BRONX-LEBANON HOSPITAL CENTER, 1650 grand Concourse, Bronx, NY, 10456, United States
Phone: 6462393204
Fax:
Title: Ondansetron Use in Children with Acute Gastroenteritis: Knowledge, Attitude and Practice of Ambulatory Health Care Providers
Folashade Farri1, Shelly Choudhury1, Emmanuel R. Kwesiga1, Roy Vega1, Ayoade Adeniyi1 and Stefan Hagmann1. 1Pediatrics, Bronx-Lebanon Hospital Center, New York, NY.
BACKGROUND: The American Academy of Pediatrics (AAP) practice guidelines for acute gastroenteritis (AGE) states that antiemetics are usually unnecessary; and that though ondansetron, can be effective in
decreasing vomiting and limiting hospital admission. reliance on medications shifts the therapeutic focus away from appropriate fluid therapy. Studies in the emergency room settings have shown that ondansetron use
was associated with less need for intravenous rehydration, and lower cost of care; So far, the use of ondansetron has not been studied in the pediatric ambulatory settings
OBJECTIVE: To assess knowledge, attitude and practices of ambulatory physicians on Ondansetron use, in children with AGE.
DESIGN/METHODS: Primary care pediatricians and family practitioners of an urban ambulatory care network in the Bronx, New York were emailed a 15-question online survey, which comprised questions about
professional and practice detail, their experience using antiemetics in the outpatient settings, followed by a survey regarding decisions on a case scenario.
RESULTS: Of 85 providers, 32 (36%) completed the survey. Most respondents were primary care pediatricians (85%), who have been in practice >10 years since residency training (70%). Overall, most (71%)
reported having ever prescribed an antiemetic for a child with AGE, and of those 19 of 32 had ever prescribed ondansetron in managing AGE. Preventing dehydration or worsening of dehydration, decreasing need for
IV fluids, and offering symptomatic relief were identified as indications for using ondansetron by 40%, 30% and 30% of the respondents, respectively. . Only 10% of the survey respondents were familiar with the AAP
practice guideline position regarding the use of antiemetic in management of AGE. . In response to a case scenario describing a 2-year old with AGE, mild dehydration, and vomiting on attempted oral rehydration
presenting in a clinic, about half (55%) would prescribe ondansetron, and the majority (80%) would observe the patient for additional time in the clinic.
CONCLUSIONS: In contrast to the current AAP practice guidelines for AGE primary care providers are likely to use ondansetron for children >2 years old with AGE in the ambulatory care setting. Further studies to
assess the safety, efficacy and cost efficiency of the use of ondansetron in children in the ambulatory setting are warranted.
Filename: 754099
Presenting Author: Naureen Memon, M.D.
Department/Institution/Address: Pediatrics, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB 312, New Brunswick, NJ, 08903, United States
Phone: 732-672-8451
Fax:
Title: Nuclear Receptor Regulation of Placental Fatty Acid Transport Proteins: Implications for Fetal Overgrowth in Maternal Obesity and Gestational Diabetes
Naureen Memon1, Kristin M. Bircsak2, Barry Weinberger1 and Lauren M. Aleksunes2. 1Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ and 2Toxicology and Pharmacology, Rutgers
University Ernest Mario School of Pharmacy, Piscataway, NJ.
BACKGROUND: More than 20% of US women are obese when entering pregnancy and 6% of women develop gestational diabetes mellitus (GDM) during the course of pregnancy. Both conditions are associated with
hyperlipidemia and fetal overgrowth. Increased fetal fatty acid availability may contribute to greater fat deposition in fetuses of obese mothers and those with GDM. The human placenta expresses several plasma
membrane-associated fatty acid transport proteins (FATP) including FATP1, FATP2, FATP4, FAT/CD36, and plasma membrane-associated fatty acid binding protein (FABPpm). Mechanisms regulating FATP
expression within the placenta have not been well characterized and identifying nuclear receptors as regulators of placental FATP expression is critical, as up-regulation of these transport proteins may play an
important role in the pathogenesis of fetal overgrowth.
OBJECTIVE: To evaluate the regulation of placental plasma membrane-associated FATP mRNA expression by the nuclear receptor peroxisome proliferator-activated receptor γ (PPARγ) in vitro.
DESIGN/METHODS: Human BeWo choriocarcinoma placental cells were treated with either vehicle or PPARγ agonist (rosiglitazone) for 48 hours. mRNA expression of FATP1, FATP2, FATP4, CD36, and FABPpm
was quantified using qPCR.
RESULTS: We detected the mRNA expression of FATP1, FATP4, and FABPpm but not FATP2 or CD36 in BeWo cells. Exposure to the PPARγ agonist, rosiglitazone, significantly decreased FATP1 and FATP4
expression by 20% and 50%, respectively. The PPARγ agonist did not alter FABPpm levels.
CONCLUSIONS: Our results suggest that activation of the PPARγ nuclear receptor may down-regulate FATP1 and FATP4 mRNA expression in placental BeWo cells. Previous studies have demonstrated decreased
PPARγ expression/binding activity in placentas of women who are either obese or have GDM. Taken together, these data suggest that PPARγ is a negative regulator of FATP1 and FATP4 expression and that
placentas of women with obesity or GDM may have elevated FATP1 and FATP4 expression leading to increased fetal adiposity and higher birth weights in infants.
Filename: 750838
Presenting Author: Dong Xi, MD, PhD
Department/Institution/Address: Department of Pediatrics, Brookdale University Hospital and Medical Center, One Brookdale Plaza, New York, NY, 11212, United States
Phone: 9177163510
Fax:
Title: Estimation of Small Intestinal Bacterial Overgrowth in Children with Different Gastrointestinal Symptoms
Dong Xi1, Puneet Arora1, Yatian Zhang1 and Radha Nathan1. 1Department of Pediatrics, Brookdale University Hospital and Medical Center, New York, NY.
BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition presenting with increased bacterial colonization, resulting in inflammation or malabsorption. But majority of patients have nonspecific clinical
symptoms. Lactulose breath test (LBT) is widely used for the diagnosis of SIBO, which is based on that the action by bacteria leads to the production of hydrogen. However the clinical symptom most likely to have
positive LBT is still unknown.
OBJECTIVE: To analyze the correlation between different gastrointestinal (GI) symptoms and positive LBT, and identify the symptom with highest positive LBT rate.
DESIGN/METHODS: Retrospective study was performed in pediatric patients who underwent LBT from 2011 to 2014. Patients presented with one or multiple GI symptoms. LBT was performed with ingestion of 10g
lactulose followed by monitoring breath hydrogen levels at 0min, 30min, 60min, 90min, 120min intervals. LBT was considered to be positive if hydrogen level was increased by 20ppm. The percentage of positive LBT
in all the patients and patients with individual GI symptom was calculated. The symptom with highest positive LBT rate was identified.
RESULTS: Totally 48 patients were tested. 34 patients (71%) were found to have positive LBT and 14 patients (29%) were negative. No difference was found in baseline level of breath hydrogen between patients with
negative LBT (19.0±5.3) and positive LBT (13.7±2.5) (t=0.31). Positive LBT showed a significant increase of hydrogen level (46.1±8.1) (t<0.01). LBT was found to be positive in 85% of patients with failure to thrive,
compared to other GI symptoms (Table 1). Failure to thrive was identified to have highest positive LBT rate.
CONCLUSIONS: Our study showed strong correlation between positive LBT and failure to thrive. LBT should be considered in patients with failure to thrive and no other etiologies.
Filename: 754161
Presenting Author: Angela Sandell, MD
Department/Institution/Address: 385 Bryant St #6, Buffalo, New York, 14222, United States
Phone: 7168078457
Fax:
Title: Pediatric Refugee Health in Buffalo, NY
Angela Sandell1, Robert Baker1, Jennifer Maccarone2, Changxing Ma1 and Susan Baker1. 1Pediatric Gastroenterology, Women and Children's Hospital of Buffalo, Buffalo, NY and 2School of Medicine and Biomedical
Sciences, SUNY at Buffalo, Buffalo, NY.
BACKGROUND: Pediatric refugees are at risk for acute and chronic malnutrition. How their nutritional status changes after resettlement is unknown.
OBJECTIVE: The objective is to characterize the change in pediatric refugee health status following resettlement in Buffalo, NY.
DESIGN/METHODS: A retrospective chart review was performed at a clinic in Buffalo, NY that sees most resettled refugees in the area. Two cohorts, ages 0-21 were selected--one with initial visits between
2007-2009 (Cohort A) and the other from 2013 (Cohort B). Descriptive, anthropometric data, and POC hemoglobin (Hb) levels were recorded. Additionally, vitamin A, D, and B12 levels were collected for Cohort B.
Body-mass-index (BMI) z-scores and height-for-age (HFA) z-scores were calculated.
RESULTS: Descriptive data are shown in Table 1.
Cohort Sex %
Birthplace %
Refugee Camp Location %
Thailand: 26.2 Thailand: 36.2
A
n=220
Male: 53.2
Myanmar: 10.6 Tanzania:15.1
Female: 46.8 Kenya:11.5
Kenya:13.8
Other: 51.7
Other: 34.9
Thailand: 25.9 Thailand: 31.6
B
n=217
Male:52.1
Nepal: 16.7
No camp: 12.6
Female:47.9 Myanmar: 12.5 Nepal: 18.1
Other: 44.9
Other: 37.7
Mean initial visit (IV) and follow-up visit (FUV) height-for-age (HFA) z-scores, BMI z-scores, vitamin, and mineral data are shown in Table 2, for all patients.
HFA
BMI
z-score
z-score
IV:-1.36
IV: 0.28
Cohort
Vitamin/Mineral Levels
A
Hemoglobin: 12.1 g/dL
FUV:-0.79 FUV: 0.59
Vitamin A:41.6 mcg/mL
IV: -1.15
IV: 0.11
Vitamin D: 20.9 ng/mL
B
FUV: -0.98 FUV: 0.40 Vitamin B12: 606.1 ng/L
Hemoglobin:12.9 g/dL
After excluding those not seen at both visits, Cohort A showed increased HFA z-scores (0.51 +/- 1.0, p<.0001) but no change for BMI z-scores (0.07 +/- 1.1, p=0.41); Cohort B showed no change in HFA z-scores
(-0.03 +/- 0.57, p=0.48) but showed increased BMI z-scores (0.22 +/- 0.72, p<.0001). For Cohort B, vitamins A (41.6 +/- 13.6 mcg/dL) and D (20.9 +/- 6.1 ng/mL) were deficient, while vitamin B12 (606.1 +/-414.4 ng/L)
was sufficient. Hb was not deficient (12.1 +/- 1.6 and 12.9 +/- 1.5 g/dL for Cohorts A and B, respectively).
CONCLUSIONS: Initially, pediatric refugees showed stunting. Height-for-age z-scores for Cohort A demonstrated catch-up growth over five years. BMI z-scores increased, significantly for Cohort B. Iron deficiency
was not present, though this was not adjusted for age. Vitamin A and D deficiency supports initial poor health status. We conclude that child refugees show malnutrition, but with resettlement, improve over time.
Filename: 752036
Presenting Author: Souvik Mitra, MD
Department/Institution/Address: Division of Neonatology, Department of Pediatrics, McMaster University, HSC 4F, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
Phone: 1-905-962-1091
Fax:
Title: Indomethacin Dose-Interruption & Maternal Chorioamnionitis: Risk Factors for Indomethacin Treatment Failure in Preterm Infants with PDA
Souvik Mitra1 and Muzafar Gani Abdul Wahab1. 1Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
BACKGROUND: Preterm infants often respond differently to Indomethacin for PDA closure with some requiring multiple courses of the drug and subsequently surgical ligation.
OBJECTIVE: To identify perinatal and postnatal risk factors associated with failure of primary course of indomethacin for treatment of PDA.
DESIGN/METHODS: We studied infants who received indomethacin for PDA between 2010-2013. We identified those who failed primary pharmacotherapy and required subsequent courses or surgical ligation.Failure
of primary course of indomethacin was defined as infants requiring more than one full course of indomethacin or received one full course of indomethacin followed by surgical ligation. Perinatal/neonatal variables in
infants with and without indomethacin failure were compared by univariate analysis. Subsequently, variables which had significant difference between the two groups were selected to carry out logistic regression
analysis.
RESULTS: Out of 77 infants, 36(46.7%) had primary indomethacin failure and nine underwent surgical ligation. Univariate analysis revealed that infants with indomethacin failure were significantly more preterm, of
male sex, did not receive a complete course of antenatal corticosteroids, indomethacin dose interruption was documented during clinical care and their mothers had clinical chorioamnionitis and.
The multivariable regression analysis showed that dose interruption and clinical chorioamnionitis were independent risk factors for indomethacin failure.
Variable
p value Odds ratio (adjusted) 95% CI
Gestational age (∆ 1 wk)
0.30
0.82
0.56, 1.20
Male sex
0.96
0.97
0.23, 4.01
Clinical Chorioamnionitis
0.007
7.80
1.73, 35.00
Dose Interruption
<0.001 27.14
5.94, 124.07
CONCLUSIONS: Indomethacin dose interruption and clinical chorioamnionitis appear to be independent risk factors for indomethacin failure in preterm infants. This study generates an important hypothesis regarding
the role of dose interruption in treatment failure.
Filename: 756323
Presenting Author: Monica L. Williams, MS
Department/Institution/Address: Neonatology, Children's Hospital of Philadelphia, ARC Rm 415H, 3615 Civic Center Blvd, Philadelphia, Pa, 19104, United States
Phone: 0012674265895
Fax:
Is Presenting Author a Trainee? Yes, Other - Post Graduate Student
Title: Nuclear Heme Oxygenase (HO)-1 Enhances DNA Repair After Hyperoxic Injury Through OGG1
Monica L. Williams1, Amal P. Fernando1, Mekdes T. Yohannes1, Ping La1 and Phyllis A. Dennery1,2. 1Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA and 22University of Pennsylvania School of
Medicine, Philadelphia, PA.
BACKGROUND: The DNA base pair adduct 8-oxo-deoxyguanosine (8 oxo-dG) is generated by oxidative DNA damage and is repaired by 8-oxoguanine glycosylase (OGG1). We have shown preliminarily that the
lungs of neonatal rodents exposed to hyperoxia have enhanced nuclear translocation of HO-1 the inducible isoform of the rate-limiting enzyme in heme degradation. This form of HO-1 is truncated at the C-terminus
and is catalytically inactive. Preliminary data show that several DNA repair proteins are associated with the nuclear HO-1 after oxidative stress. Therefore we hypothesized that during hyperoxia and in recovery,
nuclear HO-1 provides protection in DNA repair.
OBJECTIVE: To determine whether nuclear HO-1 modulates OGG-1 localization and/or function after acute hyperoxic exposure and during recovery
DESIGN/METHODS: HO-1 null mutant MEF cells were infected with retroviruses expressing full-length (FL) or C-terminal truncated (TR) HO-1 cDNA, or empty vector (VEC) as a control. Cells were exposed to either
hyperoxia or normoxia for 12hrs and 20hrs. Levels of OGG1 mRNA were evaluated using quantitative polymerase chain reaction (qPCR) and protein levels were measured by western analysis.
RESULTS: Expression of nuclear HO-1 is associated with an early increase in the nuclear accumulation of OGG1 protein, and lesser oxidative DNA damage. In the TR, OGG1 immunoreactive protein showed a
perinuclear and nuclear distribution after 12-28 hrs of hyperoxic exposure. This was not associated with increased OGG1 mRNA levels. When cells were allowed to recover in room air for up to 48hrs, only TR had
increased OGG1 mRNA. This was associated with increased nuclear Nrf2 protein. In addition, Nrf2 KO cells exposed to hyperoxia had lesser levels of OGG1 mRNA in recovery compared to WT suggesting that this
induction is mediated via Nrf2.
CONCLUSIONS: We conclude that in the early phase of hyperoxic injury TR allows for nuclear translocation of OGG1 to facilitate DNA repair. In recovery, TR promotes the induction of OGG1 mRNA via Nrf2
signaling.
Filename: 753546
Presenting Author: Mariam M. Said, MD
Department/Institution/Address: 111 Michigan Ave, NW., Washington, DC, United States
Phone: 202-476-6797
Fax: 202-476-3459
Title: Influence of Central Hemodynamics and Dual-Lumen Catheter Positioning on Recirculation in Neonatal Veno-Venous ECMO
Mariam M. Said1,2, Gerald T. Mikesell1, Oswaldo Rivera1 and Khodayar Rais-Bahrami1,2. 1Children's National Medical Center, Washington, DC and 2The George Washington University School of Medicine, Washington,
DC.
BACKGROUND: The gold standard for ECMO therapy has been venoarterial (VA) ECMO. During the last decade, an alternative approach using a dual-lumen catheter has been used with increasing frequency for
neonates with respiratory failure allowing for venovenous (VV) ECMO. The catheter is inserted into the right atrium with return of oxygenated blood, directed toward the tricuspid valve. The most attractive feature of
the dual-lumen catheter is single site cannulation of the internal jugular vein, thereby sparing the carotid artery. The major limitations of VV-ECMO is recirculation of the oxygenated blood, limiting the efficiency of the
bypass system.
OBJECTIVE: The purpose of this study was to investigate the effectiveness of VV ECMO support via a dual lumen venovenous catheter (VV15, OriGen Biomedical, Austin, TX) as a function of catheter positioning and
hemodynamic status in neonatal lamb model using an ELSA monitor (Transonic Systems Inc. Ithaca, NY). The ELSA monitor measures flow and utilizes dilution principle to measure percent of recirculation.
DESIGN/METHODS: Central hemodynamic assessment was performed prior to and during VV ECMO by measuring cardiac index (CI) in seven newborn lambs 1 to 5 days old and weighing 4.2+0.5kg. During
catheter insertion the ELSA monitor was used to find the optimal positioning with minimal recirculation. ECMO flows were increased from 200 to 600mL/min with recirculation measured by dilution with the ELSA and
calculated by measuring oxygen saturations from the SVC, IVC, pre and post- membrane.
RESULTS: Cardiac Index (CI) prior to VV-ECMO ranged from 120–310ml/min/kg. Two lambs with the lowest CI, of 120 and 130ml/min/kg, required intensive therapy and one died prior to initiating ECMO. During
VV-ECMO, lambs with higher CI (>160ml/min/kg), had a tendency to have lower recirculation (7-34%, from 200 to 600ml/min) while lambs with low CI (<120 ml/min/kg), tended to have higher levels of recirculation
(42-47%, from 200 to 600ml/min). Recirculation values calculated by blood sampling overestimate recirculation by dilution methods (bias 10%) but the two methods correlated well (R2 = 0.8).
CONCLUSIONS: Central Hemodynamic status during VV-ECMO and catheter positioning plays an important role in optimal ECMO delivery. High recirculation may suggest cardiac output failure. The ELSA monitor
provides a non-invasive method to measure recirculation and optimize catheter performance.
Filename: 754290
Presenting Author: Joanna Costa, MD
Department/Institution/Address: 6 York Road, Wilmington, DE, 19803, United States
Phone: 609-315-1735
Fax:
Title: Inflammatory Role of Pulmonary Artery Smooth Muscle Cells in Pulmonary Vascular Remodeling in Pulmonary Artery Hypertension
Joanna Costa1,2,3, Deepthi Alapati1,2,3, Yan Zhu1,2, Paul Fawcett1,2 and Thomas Shaffer1,2,3,4. 1Pediatrics, Nemours, Alfred I. duPont Hospital for Children, Wilmington, DE; 2Nemours Lung Research Center, Nemours,
Alfred I. duPont Hospital for Children, Wilmington, DE; 3Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA and 4Temple University School of Medicine, Philadelphia, PA.
BACKGROUND: Pulmonary artery hypertension (PAH) contributes to morbidity and mortality BPD and requires treatment with high concentration of oxygen and positive pressure ventilation. Both are known to induce
abnormal pulmonary vascular remodeling, the hallmark of PAH. Although inflammation is known to contribute to pulmonary vascular remodeling as evidenced by elevated serum levels of cytokines and chemokines
and cellular inflammatory infiltrate around remodeled vessels in histological specimens of patients with PAH, the underlying mechanisms are poorly understood. We previously reported that in vitro exposure of
pulmonary artery smooth muscle cells (PASMC) to hyperoxia or positive pressure ventilation (PPV) resulted in significantly increased synthesis of IL-6 and IL-8. Here, we sought to examine whether exposure of
PASMC to hyperoxia and PPV would induce production of other inflammatory mediators that have been previously implicated in PAH.
OBJECTIVE: To determine the direct effects of hyperoxia and PPV on the production of various inflammatory mediators in PASMC using our novel in vitro model of lung injury.
DESIGN/METHODS: Commercially available adult human PASMC were cultured in temperature and pressure controlled air-tight chambers and exposed to 95% FiO2 or PPV at a rate of 60 cycles per minute with
peak inspiratory pressure of 24 cm H2O and positive end expiratory pressure of 8 cm H2O, or both, for 24 hours. Control cells were cultured in room air under atmospheric pressure. After the 24 hour exposure period,
culture medium was collected and samples were analyzed by Human Cytokine 25-Plex Panel using a Luminex 200 analyzer. Data were expressed as mean +/- SEM and analyzed by ANOVA.
RESULTS: Secretion of a number of analyzed inflammatory mediators, specifically IL-2R, MIP 1β/CCL4, MCP-1/CCL2, IP-10/CXCL10, and IFN-α, was higher in the hyperoxia (95% FiO2) group compared to control
(p<0.05, n=6) and the PPV (21% FiO2-24/8 cm H2O) group compared to control (p<0.05, n=6). DAPI staining of PASMC showed a decrease in cell nuclei (p<0.05) in the combined hyperoxia and PPV group when
compared to control.
CONCLUSIONS: This is the first study to show that PASMC directly produce multiple inflammatory mediators in response to oxidative and biophysical stress. These and other mediators induced by hyperoxia and
biophysical stress may be part of a cascade that lead to the vascular and perivascular changes in PAH.
Filename: 754803
Presenting Author: Samuel Ajayi, MD
Department/Institution/Address: Neonatology, Saint Christopher's Hospital for Children, 3601 A Street, Philadelphia, PA, 19134, United States
Phone: 215-427-5202
Fax:
Title: Radiation Exposure in Very Low Birth Weight Infants in the NICU
Samuel Ajayi1, Saba Faranaz4, Saul Rubin4, David Saul2, Mindy Horrow3 and David L. Schutzman4. 1Neonatology, Saint Christopher's Hospital for Children, Philadelphia, PA; 2Radiology, Children's Hospital of
Philadelphia, Philadelphia, PA; 3Radiology, Einstein Medical Center Philadelphia, Philadelphia, PA and 4Pediatrics, Einstein Medical Center Philadelphia, Philadelphia, PA.
BACKGROUND: Very low birth weight (VLBW <1500 g ) infants in the Neonatal Intensive Care Unit (NICU) are repeatedly exposed to ionizing radiation for diagnostic purposes. Long-term effects of radiation exposure
may include an increased risk for cancer and impaired cognitive development.
OBJECTIVE: Quantify the numbers and types of imaging studies using ionizing radiation and estimate radiation exposure in a population of VLBW infants
DESIGN/METHODS: Retrospective chart review of all VLBW infants admitted to a level IIIB NICU serving an inner city population from 01/2008 to 06/2013. All infants who had at least one radiographic procedure
were included. Infants who died or were transferred were excluded. The average entrance skin doses (ESD) for neonatal chest (CXR), abdominal (AXR) and combined chest/abdomen (C&AXR) X-ray at our site were
used to calculate the total radiation exposure. We quantified X-rays based on study indication.
RESULTS: 238 infants were enrolled; 56% female, mean birth weight 1.08±0.27 kg; mean gestational age 29±2.5 weeks. The mean number (± SD) of studies for each baby was CXR 3.66±5.74 (0 – 44), AXR
2.47±3.59 (0 – 28), and C&AXR 3.70±3.32 (0 – 18). The median number of studies for each baby was CXR 2, AXR 1, C&AXR 3. Mean total ESD per baby was 48.95 mREM (range 4.5 – 317 mREM), while median
total dose per baby was 30.46 mREM. Ninety percent of neonates had an Xray for umbilical vessel catheter placement, 68% for respiratory distress, 50% for PICC line placement, 48% to rule out necrotizing
enterocolitis and 43% for endotracheal tube placement. Factors associated with increased exposure to X-rays were gestational age ≤ 28wks, 5-min Apgar score ≤ 5, birth weight ≤1kg, length of stay > 60 days, having
received antenatal steroids, and having received surfactant (p < 0.05).
CONCLUSIONS: Current recommendations by various organizations state that cumulative radiation doses below 500-2500 mREM for premature infants during the course of one year should not be concerning.
However there is currently no known safe dose for these infants. We have documented a substantial burden of ionizing radiation on the most critically ill infants in the NICU that approaches the lowest recommendation
level. Much of this exposure could potentially be replaced by ultrasound. Future studies should explore the usefulness of ultrasound as a replacement imaging modality.
Filename: 751267
Presenting Author: Alison J. Carey, MD
Department/Institution/Address: Pediatrics, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134-1095, United States
Phone: 215-427-5202
Fax:
Title: The Immature T Cell Receptor Repertoire Impairs the Neonatal CD8+ T Cell Response To Influenza Infection
Alison J. Carey1,2, Donald T. Gracias2,3, Jillian L. Thayer2, Yvonne M. Mueller2,4, Jennifer L. Hope2,4 and Peter D. Katsikis2,4. 1Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA; 2Microbiology and
Immunology, Drexel University College of Medicine, Philadelphia, PA; 3Immune Regulation, La Jolla Institute of Immunology, San Diego, CA and 4Immunology, Erasmus University, Rotterdam, Netherlands.
BACKGROUND: Despite recognition of the severity and high mortality of neonatal respiratory viral infections which have been attributed to the immunological immaturity of the newborn, the specific mechanism for this
increased susceptibility remains unclear.
OBJECTIVE: To understand the mechanisms that affect neonatal virus–specific CD8+ T cell responses, we developed a clinically-relevant model where 3-day old neonatal C57Bl/6 mice were infected intranasally with
influenza type A virus strain PR/8/34 (H1N1).
DESIGN/METHODS: 3-day old neonatal mice infected with influenza virus mount a greatly reduced lung NP(366-374)-specific primary CD8+ T cell response when compared to 7-day old neonatal and adult mice. We
sought to identify differences in the neonatal and adult wild-type T cell receptor (TCR) repertoire by performing next generation sequencing of sorted, NP(366-374)- specific CD8+ T cells from animals on day 10
post-infection. To confirm the role of the TCR in a blunted viral-specific CD8+ T cell response, we performed adoptive transfers of both non-transgenic and TCR-transgenic OVA(257-264)-specific (OT-I) CD8+ T cells into
influenza-infected hosts.
RESULTS: We found that the top shared adult clones used CDR3 sequences previously established as public clones in the mouse immunodominant NP(366-374)-specific CD8+ T cell response to influenza infection. In
direct contrast, the neonatal repertoire utilizes different, shorter CDR3 regions, and more varied V family gene usage, indicating a less focused repertoire. To further investigate the role of the neonatal TCR, adoptive
transfers of both neonatal and adult TCR-transgenic OT-I cells were done. These experiments revealed that naïve neonatal and adult OT-I cells expand equally well in neonatal and adult hosts, showing that the
neonatal environment is not suppressive to expansion of CD8+ T cells. When we adoptively transferred equal numbers of neonatal and adult non-transgenic CD8+ T cells, neonatal cells failed to expand, indicating that
the sluggish neonatal response to influenza infection is not simply due to a smaller pool of CD8+ T cells.
CONCLUSIONS: These studies demonstrate that an unfocused, less complex TCR repertoire may be responsible for reduced CD8+ T cell immunity rather than intrinsic signaling defects, a suppressive environment or
a smaller pool of CD8+ T cells, which could impact the vaccination of neonates.
Filename: 751363
Presenting Author: Laurie Hoffman, MD
Department/Institution/Address: Pediatrics, Women & Infants Hospital of RI, 101 Dudley Street, Providence, RI, 02905, United States
Phone: 401-274-1122
Fax:
Title: Developmental Intervention for Infants of Adolescent Mothers: Phase 1
Laurie Hoffman1, Alicia Hersey1, Richard Tucker1 and Betty Vohr1. 1Pediatrics, Women & Infants Hospital of RI, Providence, RI.
BACKGROUND: Infants of adolescent mothers are at risk for poor developmental outcomes. LENA, an automated processer, allows direct measures of adult speech, child vocalizations & language environment.
OBJECTIVE: To create & assess a language development intervention using LENA recordings of adult word count(AW), child vocalizations(CV) & conversation turns(CT), initiated in the hospital & sustained via text
messaging for infants born to adolescent mothers.
DESIGN/METHODS: RCT of infants ≥30 wks born to mothers 15-19 yo. Participants are randomized to language intervention(I) or motor control(C). In phase 1, each infant has a baseline 16hr LENA recording(R1).
After R1, the I group receives linguistic feedback of R1 & reviews a language/motor activities handout. The C group receives a motor handout. A 2nd recording(R2) is done after the feedback session. Results of I in
Phase 1 are presented. Analyses include group comparisons with T-test, Χ2, neg binomial regressions & generalized estimating equation. In phase 2, recordings & follow-up assessments are done at 4 & 12m.
Mothers in the I group receive 16 weekly texts reviewing language/motor handouts & linguistic feedback on each LENA. Mothers in the C group receive 4 monthly-texts reviewing motor handout (in progress).
RESULTS: The cohort includes 92 infants (50I, 42C). Groups had similar infant (gest, M/F, BW, LOS, morbidities, insurance, R1 age), maternal (age, grav, education) & household characteristics, except I mothers
were more likely para1 (p=.02), had [dar adults in home (p=.04) & I infants had ↑ R2 age (8.2v 13.4d, p=.006). LENA analyses were corrected for R2 age.
The C group had ↑ AW on R1 but ↓on R2 than I group. Between R1 & R2, daily CV & CT ↑ sig in the I group & ↓in C group.
CONCLUSIONS: An in-hospital language intervention with adolescent mothers using simple written handouts and linguistic feedback resulted in short term sig ↑CV & CT & trends for ↑AW. Continued assessment of
this cohort will determine if the I is assoc with a sustained ↑in AW, CV & CT & ↑language skills at 12m of age.
Filename: 751249
Presenting Author: Khushbu Shukla, MBBS
Department/Institution/Address: Department of Pediatrics, Women & Infant's Hospital of Rhode Island, 101 Dudley Street, Providence, RI, 02905, United States
Phone: +1 (361) 960-6622
Fax:
Title: Non-Invasive Airway Resistance Measurement in Neonates
Khushbu Shukla1, Alyse M. Laliberte1, Jafar Vossoughi2, Arthur Johnson3 and Martin Keszler1. 1Department of Pediatrics, Women & Infants Hospital of Rhode Island, Brown University, Providence, RI; 2ESRA,
Brookeville, MD and 3Department of Bioengineering, University of Maryland, College Park, MD.
BACKGROUND: Former preterm infants with bronchopulmonary dysplasia (BPD) have high airway resistance (AR) and may have reactive airway disease. It is desirable to assess their lung function and need
for/response to bronchodilators. This requires a simple, reliable device that could measure AR non-invasively without active collaboration of the patient. The Neonatal Airflow Perturbation Device (NAPD) developed
under an SBIR grant may serve this purpose. The adult version has been successfully used in adults and older children. The NAPD has been modified for use in neonates.
OBJECTIVE: To validate the ability of the NAPD to measure AR reproducibly in neonates and demonstrate its safety.
DESIGN/METHODS: The NAPD was used to measure AR at the bedside in stable neonates not requiring respiratory support. Data were recorded for 1 minute in triplicate. Infants were studied in a quiet awake or
sleeping state without sedation. SPO2, HR and RR were monitored and values recorded pre and immediately post measurement. Transcutaneous CO2 monitoring was performed in the first 20 subjects. Data were
analyzed by least square means.
RESULTS: We studied 40 subjects using four NAPD devices. Despite some statistically significant differences, all vital signs remained normal, without adverse events.
Mean Before (S.E) Mean After (S.E) P-value
Heart rate (beats/min)
151 (2.1)
0.04
Repsiratory Rate (breaths/min) 55 (2.2)
154 (1.9)
59 (2.6)
0.04
Oxygen saturation (%)
98 (0.24)
97 (0.26)
0.001
Transcutaneous CO2Monitor
44 (1.3)
45 (1.4)
0.73
Individual NAPD devices gave reproducible results (within 10%), though they varied from one another.
CONCLUSIONS: The NAPD is easy to use, safe and capable of reproducible measurement of airway resistance. The variability of values between devices suggests a calibration issue that is being addressed.
Subsequent studies will compare NAPD measurements to those obtained by body plethysmograph and measure response to inhaled bronchodilator.
Funding: NIH funded SBIR grant (5R43HL106366-02) to Jafar Vossoughi.
Filename: 750110
Presenting Author: Michael Amberson
Department/Institution/Address: 214 Chestnut St #3, Cambridge, MA, 02139, United States
Phone: +1 (774) 258-1488
Fax:
Title: Cost Analysis of Home Monitor Utilization To Facilitate Earlier Discharge in Late Preterm and Full Term Infants with Apnea
Michael Amberson1,2, Lauren Veit1,3, Dmitry Dukhovny4 and Lawrence M. Rhein1,5. 1Division of Newborn Medicine, Boston Children's Hospital, Boston, MA; 2Boston University School of Medicine, Boston, MA;
University of Massachusetts School of Medicine, Worcester, MA; 4Oregon Health & Science University, Portland, OR and 5Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA.
BACKGROUND: A subset of preterm (PT) and full term (FT) infants are known to have persistent apneic events that can delay home discharge. Two distinct management strategies are commonly used: (a) inpatient
(inpt) observation until apnea resolution vs (b) use of caffeine and discharge with home monitor, which may allow shorter hospitalizations. Data comparing cost of these 2 distinct strategies is lacking.
OBJECTIVE: We aim to determine potential cost savings of outpatient (outpt) treatment of apnea compared to inpt monitoring until apnea resolution.
DESIGN/METHODS: We conducted a retrospective study of late PT and FT neonates born from 2009-13 at 2 tertiary care institutions in Boston, MA. Infants were included if they were inborn at one of the 2 hospitals
between 2009-13 at gestational age >= to 34 0/7 weeks, and had documented events of apnea, bradycardia, or desaturation within 6 days of discharge. Infants were excluded if they had a comorbid diagnosis either
associated with or predisposing to apnea (e.g. infection). Using data from this cohort, we applied models which varied duration of observation (a) after reaching all other discharge criteria except for apnea, and (b)
after initiation of caffeine prior to discharge home with a monitor until 44 weeks postmenstrual age. We then compared estimated costs with this theoretical strategy (in 2013 US dollars) with estimated costs of the
alternative management strategy, continued inpt observation until resolution of apnea.
RESULTS: Strategies with shorter duration of observation, both after oral feeding maturity and again after caffeine initiation, generated the most potential cost savings. Using durations of observation that are more
commonly utilized still generated significant potential savings.
3
CONCLUSIONS: Given potential cost savings of strategies utilizing home monitors and caffeine, prospective studies are needed to compare safety and patient satisfaction of inpt and outpt apnea management
strategies in late PT and FT infants.
Filename: 754874
Presenting Author: Dalal Taha, D.O.
Department/Institution/Address: Neonatology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Main Building, 2nd Floor, Philadelphia, PA, 19104, United States
Phone: 215-590-1653
Fax:
Title: High-Flow Nasal Cannula and CPAP Use in Extremely Low Birth Weight Infants
Dalal Taha1, Michael Kornhauser3, Jay S. Greenspan2 and Zubair H. Aghai2. 1Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; 2Pediatrics/Neonatology, Thomas Jefferson University/Nemours,
Philadelphia, PA and 3Alere, Waltham, MA.
BACKGROUND: High-flow nasal cannula (HFNC) is increasingly being used as a mode of noninvasive respiratory support for preterm infants. Unregulated distending pressure generated by HFNC may be injurious to
the lungs.
OBJECTIVE: To compare neonatal outcomes with the use of HFNC versus continuous positive airway pressure (CPAP) in extremely low birth weight (ELBW) infants.
DESIGN/METHODS: This study is aretrospective data analysis from the Alere Neonatal Database for infants born between 01/08 and 09/13, weighing ≤ 1000 grams, and received HFNC or CPAP. Baseline
demographics, clinical characteristics, and neonatal outcomes were compared between the infants who received CPAP and HFNC or HFNC+CPAP.
RESULTS: A total of 2,820 infants met the inclusion criteria. 941 infants were in the CPAP group (BW 787±145 g, GA 26.7±2.1 w), 333 infants were in the HFNC group (BW 776±149 g, GA 26.5±1.9 w), and 1,546
were in the HFNC+CPAP group (BW 773±146 g, GA 26.3±1.8 w). There was no significant difference in BW, GA, 5 minute Apgar score, ventilated on day 1 of life, and surfactant use between the CPAP and HFNC
groups. However, these parameters differ between the CPAP and HFNC+CPAP groups. The number of ventilator days, days to room air, use of postnatal steroids and the number of infants with bronchopulmonary
dysplasia (BPD) were significantly higher in the HFNC group compared to the CPAP group (Table 1). Days to begin PO feeds, days to full PO feeds and length of hospitalization were significantly higher in the HFNC
and HFNC+CPAP groups compared to the CPAP group.
CPAP days
CPAP
HFNC
HFNC+CPAP
(941)
(333)
(1546)
17.0±15.6
16.6±15.3
18.5±16.2
HFNC days
12.1±13.9
CPAP and/or HFNC
18.5±16.2
17.0±15.6
28.7±20.4**
Ventilator days
23.9±29.4
28.9±33.4*
36.0±37.6**
Postnatal steroids
115 (12.2)
71 (21.3)*
387 (25.0)**
Days to RA
66.0±39.7
79.1±43.2*
86.8±45.4**
BPD (%)
397 (42.2)
174 (52.2)
912 (59.0)^
* CPAP vs HFNC, p<0.05
**CPAP vs HFNC+CPAP, p<0.05 after correcting for BW, GA, 5 min
Apgar score, ventilated on day 1, ventilator days and use of surfactant
(multiple linear regression)
^CPAP vs HFNC+CPAP (multiple logistic regression) odds ratio for
developing BPD when on HFNC+CPAP 1.587 (95% CI, 1.436-2.376,
p<0.001)
CONCLUSIONS: Use of HFNC in ELBW infants is associated with increased respiratory morbidities, delayed PO feeding and prolonged hospitalization. A large clinical trial is needed to evaluate safety and efficacy of
HFNC in preterm infants.
Filename: 754865
Presenting Author: Mary A. Woodward, MBBS,MD
Department/Institution/Address: Division of Neonatology, Department of Pediatrics, McMaster Childrens Hospital, 1200 Main Street West, Hamilton, Ontario, L8N3Z5, Canada
Phone: 1-289-680-2584
Fax:
Title: Mortality, Morbidity and Resource Use Among Infants With Trisomy 21(TR21) Admitted To Level III (L3) NICUs
Mary A. Woodward1, Connie Williams1, Abhay Lodha2, Prakesh S. Shah3 and Sandesh Shivananda1. 1Division of Neonatology, Pediatrics, McMaster Childrens Hospital, Hamilton, ON, Canada.
BACKGROUND: TR 21 is by far the most common and well known chromosomal disorder in humans and a common cause of intellectual disability. However, the lack of outcome and resource utilization details among
infants with TR 21 admitted to Level 3 NICU's precludes effective antenatal counseling, anticipation of hospital course and resource planning .
OBJECTIVE: To determine (i) the mortality, morbidity and resource utilization among infants with TR 21 admitted to L3 NICU (ii) Factors associated with mortality during hospital stay.
DESIGN/METHODS: A retrospective cohort study on infants admitted to the NICU's participating in the Canadian Neonatal Network for the epochs 2004-2009 and 2010-2013 was conducted. Data on demography,
resource utilization and outcomes during hospital stay were collected. Association between outcomes (death, length of stay and oxygen at discharge) and predictors (gestational age, gender, outborn, severity of
illness (SNAP score), mechanical ventilation (MV) and inotrope use were analyzed.
RESULTS: 482 and 438 infants with TR 21 during the two epochs (1 % each of all L3 NICU admissions) were identified. The mean (SD) gestational age was 36.5(3) and 36.4(3) weeks respectively in the two epochs.
In the second epoch, 21 (5%) infants died, 21(5%) of the infants required inhaled nitric oxide and 14(3%)infants had late onset sepsis. The odds of higher deaths of TR 21 infants were associated with the use of
inotropes. On logistic regression analysis, SNAP score, MV and inotrope use had fair association with death, [odds ratio (95 % confidence interval) 0.98(0.94,1.03), 11.1(0.95,129.7) and 75.1(10.7,530) respectively.
Characteristic
No of
infants (%)
Mechanical ventilation
115 (26)
Central line
157 (36)
Inotrope use
43 (10)
Antibiotics
244 (56)
Inhaled Nitric oxide
21 (5)
Laparotomy
49 (11)
G Tube at discharge
9 (2)
Oxygen at discharge
53 (12)
Duration
Length of stay
Median
(IQR)
14 (7,30)
Mechanical ventilation
days
0 (0,1)
Oxygen days
2 (0,7)
TPN days
0 (0,7)
Resource utilization during NICU stay (2010-2013, second epoch)
CONCLUSIONS: Infants with Trisomy 21 admitted to L3 NICU have a significant mortality rate and receive a fair degree of intensive care support. Results could be used for improving effectiveness of antenatal
counseling, planned serial cardiac function monitoring as well as facilitating resource planning at various levels of health care administration.
Filename: 756022
Presenting Author: Batoul Elamin, MD
Department/Institution/Address: Division of Neonatal-Perinatal Medicine, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Suite 3400, Washington D.C., District of Columbia, 20007, United
States
Phone: 2024448569
Fax:
Title: Improving Delivery of Mother's Own Milk To Premature Infants ≤ 34 Weeks in a Tertiary Care NICU
Batoul Elamin1, Karen Kamholz1, Gail Flory1, Kelsey Capper1 and Melissa Scala1. 1Department of Pediatrics, Division of Neonatology, Medstar Georgetown University Hospital, Washington, DC.
BACKGROUND: Feeding maternal breast milk (MBM) improves outcomes in preterm infants. While processed donor breast milk (PDBM) can improve feeding tolerance and reduce the incidence of surgical
necrotizing enterocolitis compared to preterm formula, it lacks many of the beneficial factors present in MBM. At MedStar Georgetown University Hospital Neonatal Intensive Care Unit (NICU), PDBM is offered to
infants whose mothers have inadequate supply. PDBM accounted for 50-60% of breast milk feeds in our preterm infants.
OBJECTIVE: To improve delivery of MBM to preterm infants ≤ 34 weeks gestational age (GA) with a goal of 80% MBM feeds.
DESIGN/METHODS: A multidisciplinary team was formed in January 2014 consisting of neonatologists (2), NICU fellow, neonatal nurse, lactation consultants, speech pathologist, obstetrician, labor and delivery and
postpartum unit supervisors.
Monthly meetings monitored progress of proposed changes using the QI Model for Improvement. Study outcome is the percentage of infants on MBM feeds, assessed monthly.
Interventions included: 1. Securing free hospital grade breast pumps for eligible mothers, 2. Physician education, 3. Self learning nursing module on pumping devices and use, 4. Coming to Volume assessment tool
screening for marginal MBM supply and prompting lactation consult and 5. Mandatory nursing lectures on breastfeeding benefits.
RESULTS: 91 infants were included (October 2013 - October 2014). Mean GA 30 weeks ± 2.9 weeks with a mean birth weight 1477 g ± 543 g.
The largest improvement in MBM occurred after NICU nursing education
Institution of intervention 4 increased MBM at full feeds by 36%.
CONCLUSIONS: A multidisciplinary team approach, education and collaboration help identify issues that need to be addressed and effect noticeable change improving availability of MBM to preterm infants.
Through ongoing efforts we hope to continue addressing and identifying barriers to improving MBM availability and further improve preterm outcomes.
Filename: 750748
Presenting Author: Batoul Elamin, MD
Department/Institution/Address: Division of Neonatal-Perinatal Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd, NW, Washington, DC, 20007, United States
Phone: 202-444-8569
Fax: 2024444747
Title: Immmature Breathing Pattern at Discharge in Moderately Preterm Infants
Batoul Elamin1, Allison Greenleaf1, Michelle Peterson1, Deborah Hoy1 and Jayashree Ramasethu1. 1Department of Pediatrics, Division of Neonatology, Medstar Georgetown University Hospital, Washington, DC.
BACKGROUND: The margin of safety for discharge after apnea in preterm infants is accepted as 5-7 event free days, often prolonging hospitalization, particularly for infants on caffeine. The reported 15% prevalence
of apnea in moderately preterm infants [MPI; 32 -34 weeks 6 days gestational age (GA)], may be an underestimate due to unreliable nursing documentation.
OBJECTIVE: To study the impact of pre and post discharge Documented Event Monitoring[DEM] in the recognition of apnea in MPI.
Hypothesis: Predischarge and home DEM improves diagnosis of apnea in MPI, permitting safe discharge.
DESIGN/METHODS: Retrospective cohort study of MPI admitted to Georgetown NICU in 2012-13.
[Exclusions: chromosomal/ major congenital anomalies, severe IVH/ PVL, home oxygen].
Significant Event [SE] defined as apnea>20 seconds or apnea 15-20 seconds with heart rate (HR) <80/min or HR deceleration>10 bpm.
Nursing documentation of SE [NDSE] within 7 days predischarge was compared with predischarge 48 hour DEM [Philips Respironics Smart Monitor]; postdischarge DEM was reviewed.
Statistical tests: student t test, chi square. Data shown as mean± SD.
RESULTS: Of 122 MPI (GA 33.6 ± 0.8 wks, birth weight 2055 ± 366 gms), 59 (48%) had no NDSE within 7 predischarge days.
Predischarge DEM in 29 (49%) of the 59 infants revealed SE in 9 (31%).
In 63 infants (52%) with NDSE
, DEM confirmed SE in 32 (51%).
Birth wt, GA, gender, and length of stay (LOS) was similar in infants with or without NDSE. Median LOS was 20 (range 6-58) days, with mean GA at discharge 36.7 ± 1.1 wks. Caffeine was continued on discharge in
34 infants (28% of 122, birth GA 33.1± 0.8 wks).
Of 58 infants on home DEM, records were available in 55: 35 (63%) continued to show SE. Mean GA at home DEM discontinuation was 43 ± 3 wks. Only 1 infant was readmitted (for RSV infection).
CONCLUSIONS: DEM revealed an immature breathing pattern in 30-50% of MPI before and after discharge.
Home apnea monitoring may allow safe and early discharge of MPI infants, even if on caffeine.
Filename: 755276
Presenting Author: Brittany M. Reid, MD
Department/Institution/Address: Pediatrics, INOVA Children's Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, United States
Phone: 732-881-4958
Fax:
Title: Coagulation Status in Premature Infants with Low Birth Weight
Brittany M. Reid1, Edwin Doe1 and Tress Kitaeff1. 1Neonatal Intensive Care Unit, INOVA Children's Hospital, Falls Church, VA.
BACKGROUND: Current standards for PT, aPTT, and fibrinogen are 10-15 sec, 27-74 sec, and 1.5-4.2g/L respectively (Brit J of Haematol 2002). Unfortunately, most research concerning neonatal coagulation has
been performed on term or late-preterm newborns. Several studies have shown that premature infants, especially those of low birth weight, are prone to having coagulopathy. Furthermore, some data suggests that
certain conditions also contribute to coagulation problems in newborns. However, there is still little objective data on coagulation properties for neonates with low birth weight. This has lead to controversy about what is
normal for preterm infants with LBW and how to best interpret their laboratory results. We aim to distinguish the coagulation status of neonates ≤ 1250 grams and assess their relation to specific maternal and perinatal
factors at time of delivery.
OBJECTIVE: To investigate the coagulation factors of premature neonates at birth and assess the relation of maternal and perinatal factors at time of delivery.
DESIGN/METHODS: Retrospective Chart Review
We identified charts of neonates that weighed ≤1250g, were born at INOVA Children's Hospital between Jan 2008-Dec 2012, and had coagulation factors drawn on admission.
RESULTS: Approximately 600 neonates met inclusion criteria, and we have analyzed 117 neonates to date. This data set contains 45.3% female and 54.7% male premature infants with a mean GA of 26.8 weeks (CI
26.4 – 27.2, SD 0.193). Mean platelets, PT, aPTT and fibrinogen on admission were 234.9 x 103/µL (CI 218 – 251.8), 19.3 sec (CI 18 – 20.5), 66.1 sec (CI 62.5 – 69.7), and 147.8 g/dL (CI 128.8 – 166.7) respectively.
Preliminary results show positive correlation between most admission coagulation levels and the presence of abruption, chorioamnionitis, prematurity, gestational diabetes, and PROM (correlation coefficients >0.3 and
p-value < 0.05).
CONCLUSIONS: Thus far, we can conclude that the overall coagulation status of LBW premature infants reveals differences in the PT and fibrinogen levels when compared to the current standards. When coagulation
values are correlated with certain risk factors, there are conditions that appear to have an affect on coagulation shortly after birth. Further analysis will be done to discern whether these correlations are directly related
to the lab values or if they are the result of associations between other risk factors. Regardless, this study has great potential in providing information regarding clinical intervention in the future.
Filename: 755606
Presenting Author: Elvira Parravicini, MD
Department/Institution/Address: Pediatrics, Columbia University, 3959 Broadway CHN 1213, New YOrk, NY, 10032, United States
Phone: 212-305-0955
Fax: 212-305-8796
Title: Parental Assessment of Comfort in Infants Affected By Life-limiting Or Terminal Conditions Treated With a Personalized Comfort Care Management
Elvira Parravicini1, Margherita Daho'2 and Emanuela Saita2. 1Pediatrics, Columbia University, New York, NY and 2Psychology, Universita' Cattolica Sacro Cuore, Milano, Italy.
BACKGROUND: Perinatal detection of life-limiting and terminal conditions leads to identification of infants with short life expectancy. There is no current evidence–based standard of care for this population. At Morgan
Stanley Children's Hospital of New York-Presbyterian (MSCHONY) guidelines for a personalized medical plan of care focused on infant's comfort have been developed; however, evaluation of the effectiveness of this
management in promoting infant's comfort is essential.
OBJECTIVE: To assess the state of comfort in infants affected by life-limiting or terminal conditions and treated with personalized comfort measures as perceived by their parents.
DESIGN/METHODS: This is an observational study of 17 infants diagnosed with life-limiting (15) and terminal condition (2) whose parents elected comfort care. The infants were born at MSCHONY from 2011 to 2014
and treated with personalized comfort measures including family/infant bonding, warmth, nutrition/hydration and pain/discomfort management. The parents of these infant consented to receive a questionnaire aimed
to assess each baby's state of comfort during the admission. Twenty-four quantitative questions aimed to explore the parental perception of the environment, the adequacy of professionals' plan of care and parents'
opportunity to bond and take care of the baby's basic needs. Descriptive statistical analysis was performed on the anonymous questionnaires returned by the families.
RESULTS: Twenty-two questionnaires (12 from mothers and 10 from fathers) were collected and analyzed. Both mothers and fathers reported that their child was treated with respect, in a comfortable, peaceful and
non-invasive environment. Most mothers and fathers thought that their child has been fed properly, did not feel pain and was satisfied in their fundamental needs. Nearly all parents stated to have had the opportunity
to take direct care of their baby (i.e. kangaroo care, nutrition) and that their baby had opportunity to receive comfort and love from the family. Lastly, to the question “Do you think that overall your baby received
comfort” all fathers and 11/12 mothers answered “always”.
CONCLUSIONS: This study, although limited by a small number of patients, shows that parents of infants with life-limiting or terminal conditions strongly perceive a state of overall comfort of their baby as a result of
the personalized plan of comfort measures.
Filename: 752574
Presenting Author: Ronnelle S. King, MD
Department/Institution/Address: Pediatrics, Baystate Children's Hospital, 759 Chestnut Street, Springfield, MA, 01199, United States
Phone: 413-794-2400
Fax:
Title: Impact of Maternal Medically Assisted Treatment Medications on Neurodevelopmental Outcomes of Infants Treated for Neonatal Abstinence Syndrome
Ronnelle S. King1,2, Paul Visintainer1,2, Sheila Foss1 and Rachana Singh1,2. 1Baystate Children's Hospital, Springfield, MA and 2Tufts University School of Medicine, Boston, MA.
BACKGROUND: Medically assisted treatment (MAT) for illicit/prescribed opioid use in pregnancy may improve perinatal outcomes. In-utero exposure to MAT medications may have negative neurodevelopmental
(cognitive and behavioral) impact for exposed children.
OBJECTIVE: To assess impact of maternal MAT medications on the long term neurodevelopmental outcomes of infants with NAS.
DESIGN/METHODS: Historical cohort study of infants with NAS from Jul 2006 to Jul 2013. Infant, maternal and Early Intervention (EI) data were obtained from infant electronic and MA DPH EI records. Four maternal
cohorts identified - MAT after pregnancy diagnosed (Gp 1), in MAT prior to conception (Gp 2), active illicit drug use, not in MAT (Gp 3) and prescribed opioid for chronic pain (Gp 4). Univariable as well as multivariable
analyses done.
RESULTS: Cohort characteristics for the 267 infants are shown in table. 37.6% of mothers were still using illicit drugs while in MAT. For 172 infants with matched EI data, 47% were receiving EI services at 6 and 12
months of age and of the infants who had reached 24 months, 21.5% were still receiving services. No difference noted between the maternal Gp 1 and 2.
Full Cohort (N =
267)
%
Infant Characteristics:
Gestational Age (wks)
37.9 ± 2.6
Birth weight (kg)
2.92 ± 0.62
Ethnicity
Caucasian
75.5
Hispanic/Latino
13.8
African - American
3.6
Breastfeeding
21.0
Length of Hospital stay (days)
24 ± 11.6
Dischargedisposition -Foster care
25.1
Maternal Characteristics:
Maternal age (yrs)
28.3 ± 5.1
MAT medication
Methadone
66.8
Buprenorphine
33.2
Additional exposure
Alcohol
7.9
Tobacco
56.9
Marijuana
16.3
Illicit drug use while in MAT*
37.6
Early Intervention services at:
6 months
47.1
12 months
47.1
24 months**
20.4
* Includes cocaine, heroin, illicit oxycodone, buprenorphine
** Partial data as not all infants not at 24 months
CONCLUSIONS: While MAT may improve perinatal outcomes in opioid exposed pregnancy, chronic in-utero exposure to MAT medications can negatively impact neurodevelopment as noted by the increased EI
services utilization. While counseling parents, this should be discussed and greater efforts are needed to wean mothers off MAT medications prior to pregnancy conception.
Filename: 752783
Presenting Author: Justin R. Goldstein, MD
Department/Institution/Address: 601 Elmwood Avenue Box 777, Rochester, New York, 14642, United States
Phone: 1-781-408-9090
Fax:
Title: Measurement of Tensile Forces on Various Patch Materials for Congenital Diaphragmatic Hernia Repair Using a Novel Testing Platform
Justin R. Goldstein1, Scott H. Seidman2, Louisa Bauer2, Asia Ingram2, Megan Stockdill2, Jessica Yohay2 and Patricia R. Chess1,2. 1Pediatrics/Neonatology, University of Rochester, Rochester, NY and 2Biomedical
Engineering, University of Rochester, Rochester, NY.
BACKGROUND: CDH is a devastating congenital defect carrying a mortality rate of approximately 40-60%. Despite improvements in medical support and surgical methods in the past 2-3 decades, mortality and rate
of hernia recurrence remain high. The highest mortality is seen in patients requiring a patch repair, especially in those that re-herniate. The goal of this project was to create a testing platform to measure the tensile
forces on surgical patches and determine the reason for patch failure, with an ultimate aim of using this platform to test new patch materials, insertion techniques and patch folding/expansion paradigms in CDH repair.
OBJECTIVE: To create a testing platform that measures the tensile forces exerted on CDH patches of various materials, shapes and sizes.
DESIGN/METHODS: A testing platform was created to model any size and shape of diaphragmatic hernia and measure the forces exerted on a patch repair due to various stressors. It was designed to measure strain
on the patch sutures via a custom strain gauge circuit due to both long term forces (chest wall growth) and short term forces (breathing). The strain gauges were calibrated so that an output in the form of millivolts is
easily converted to a force measurement (Newton's).
RESULTS: Materials of higher tensile strength exert more forces on sutures than those with lower tensile strength in identical conditions. These forces are linear with respect to expansion of chest wall diameter over
time. Perpendicular forces on the patch/diaphragm assembly such as breathing movements exert far less force (20-30%) compared to a parallel force (chest wall expansion), and the effects of breathing forces
decrease significantly as chest diameter increases.
CONCLUSIONS: We have shown that this custom testing platform and force measurement system accurately measure tensile forces exerted on CDH patch sutures during both chest wall growth and breathing
movements. The forces exerted by breathing are far smaller than those created by chest wall growth, demonstrating that long term growth of a child has significantly more influence on patch failure than short term
forces. This platform will allow for novel folding paradigms to be investigated to determine the feasibility of an expandable CDH patch.
Filename: 754084
Presenting Author: Semsa Gogcu, MD
Department/Institution/Address: Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, New York, 10595, United States
Phone: 9176750260
Fax: 9144931005
Title: Birth Hospital Level Correlates With Long Term Neurocognitive Outcomes of Very Low Birth Weight Infants
Semsa Gogcu1, David Aboudi1, Jordan Kase1 and Heather Brumberg1. 1Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla,
NY.
BACKGROUND: Regionalized perinatal care has been linked to improved short term outcomes of very low birth weight infants (≤1500 g, VLBW). However, little is known about the impact of level of care at birth
hospital on long term neurodevelopmental (ND) outcomes of these infants.
OBJECTIVE: To evaluate the relationship of level of care at birth hospitals with ND delays significant enough to qualify for therapeutic services [Early Intervention (EI), Physical Therapy (PT), Occupational Therapy
(OT), Speech Therapy (ST), & Special Education (SE)].
DESIGN/METHODS: This is a retrospective study of former VLBW infants evaluated at our Regional Neonatal Follow-up Program of Westchester Medical Center in NY at 12± 1 months corrected age between
7/03-2/14. All were inborn (Level 4) or born at network hospitals (Level 1, 2, 3) and transferred to Level 4. ND outcomes were compared for Level 1[(Well Baby Nursery (WBN)]vs. 2, 3, and 4 (NICU). For analysis, χ²,
Fisher's exact test, t-test, ANOVA and test for trends were used. p<0.05 was significant.
RESULTS: Of 1392 infants evaluated, 344 were VLBW, with 287 inborn and 57 outborn (24, 15, 18 from Levels 1, 2, 3 respectively). Mean birth weight (BW) and gestational age (GA) did not differ by hospital level.
Although receipt of EI did not differ by hospital level [92%, 73%, 78%, 68% at Levels 1, 2, 3, 4 respectively (p=0.08)], test for trends showed an increase in receiving EI as birth hospital level decreased (p=0.02). Rates
of receiving EI and PT were higher in WBN vs. NICU hospitals [92% vs 69% (p=0.02), 83% vs 63% (p=0.049) respectively]. Of babies born at WBN, the odds of getting EI was 4.9 (CI: 1.1-21.4) compared to those
born at NICU hospitals. There was no difference in usage of OT, ST or SE by hospital level. Factors that were significantly associated with receiving EI included GA, BW, older maternal age, 5min Apgar<7 (A<7),
caffeine use, bronchopulmonary dysplasia, postnatal steroids, severe intraventricular hemorrhage (IVH), and retinopathy of prematurity. WBN had lower rates of antenatal steroids and premature rupture of
membranes, and higher rates of A<7 and severe IVH compared to NICU hospitals.
CONCLUSIONS: Our data demonstrate that VLBW infants born at WBN qualify for therapeutic services more than those born at NICU hospitals. We speculate that the lack of NICU facilities, specialized equipment
and associated experienced staff in resuscitation in WBN may negatively impact long term ND outcomes.
Filename: 753841
Presenting Author: Arjun Chandran, MD
Phone: 732 745 8523
Fax:
Title: Using Continuous Feeds in Preterm Infants ≤ 1000 gms To Reduce the Incidence of BPD
Arjun Chandran1, Jodi Young1 and Shakuntala Chandra1. 1Division of Neonatology, Department of Pediatrics, Saint Peters University Hospital, New Brunswick, NJ.
BACKGROUND: Bronchopulmonary disease (BPD) defined as oxygen dependency at 36 weeks of corrected gestational age. Large number of preterm infants require ventilator support, have a higher incidence of
gastroesophageal reflux. There are some anecdotal reports that continuous feeds prevent reflux thereby microaspiration preventing inflammation and reduced ventilatory needs and hence BPD. We wanted to
examine this relationship in our practice and culture. Our incidence of BPD in 2013 was 14.1% in comparison to Vermont Oxford Network range of 12-31%
OBJECTIVE: To begin and improve compliance with continuous feeds in preterm infants ≤ 1500 gms and also examine the outcome of BPD and persistent pulmonary hypertension(pphn)
DESIGN/METHODS: Intervention included:Change from bolus feeds to continuous feeds 10 hrs. on 2 hrs. off.We measured: Time to reach full feeds which was equated to day of life off hyperalimentation (HAL), Day
of life off respiratory support, BPD, Persistent pulmonary hypertension (PPHN) in the infants in both groups.2 similar groups were compared with similar characteristics.Inclusion criteria: All infants' ≤ 1500 gms born at
Saint Peters University Hospital in specific defined period before and after intervention Exclusion criteria: Death within 3 days of lifeGroup 1 included all infants ≤ 1500 grams between May 2013 and Sept of
2013Group 2 included all infants ≤ 1500 grams between Oct 2013 and sepof 2014These groups were chosen since we changed our practice of feeding regimen and started continuous feeds in all infants ≤ 1500
grams in an attempt to bring changes in the incidence of BPD from Oct of 2013
RESULTS: We improved our compliance with continuous feeds from 0 to 63% to 76% in this quarter in infants < 1500 gms and 100% compliance with infants <1000 gms. We analysed infants < 1000gms due to 100%
compliance. Mean days off hyperalimentation reduced from 34.2±15.5 days to 25.9±12.4 days (p=0.08), mean days off resp support improved from 62.06±16.4 to 52.7±28.2 days (p=0.2), BPD improved from 20% to
14.2% (p=0.6) ppnh from 5 to 4.7%(p=1) in infants < 1000gms
CONCLUSIONS: We achieved 76% compliance with continuous feeds after implementing the new practice in infants < 1500 gms and 100% compliance with continuous feeds in preterm infants < 1000gms on
continuous feeding Infants on continuous feeds showed a trend in achieving full feeds earlier, reduced number of days on respiratory support and had lower incidence of BPD and PPHN
Filename: 752865
Presenting Author: Michelle B. Levinson, MD
Department/Institution/Address: Pediatrics, Stony Brook Children's Hospital, HSC Level 11, Room 040, Stony Brook, NY, 11794-8111, United States
Phone: 631-444-2020
Fax: 631-444-8968
Title: Is Excess Fluid Administration Shortly Following Birth in Very Low Birth Weight Neonates Associated With an Increased Rate of Patent Ductus Arteriosus Requiring Treatment?
Michelle B. Levinson1 and Jonathan P. Mintzer1. 1Pediatrics, Stony Brook Children's Hospital, Stony Brook, NY.
BACKGROUND: In the NICU, fluid balance requires tight regulation in very low birth weight neonates (VLBW; < 1500 g BW). Shortly after birth, VLBWs receive fluids from multiple sources which may exceed intended
fluid goals. Previous studies have shown an increased incidence of patent ductus arteriosus (PDA) in VLBWs receiving excess fluids shortly following birth. Very few studies have examined the effects of excess fluids
in VLBWs during the first postnatal day. We hypothesize that in VLBWs, excess fluid in the first day of life beyond prescribed goals is associated with an increased incidence of PDA requiring treatment.
OBJECTIVE: To determine whether excess fluid in VLBWs beyond prescribed fluid goals during the first postnatal day is associated with PDA requiring medical and/or surgical treatment, in addition to other common
neonatal morbidities.
DESIGN/METHODS: This retrospective chart review included consecutive VLBWs with complete electronic records. Fluids administered in the first 24 postnatal hours were compared to documented fluid goals on
admission. A 15 % discrepancy between prescribed and total administered fluids was defined as “excess.” Subjects were categorized into excess vs. non-excess fluid groups, which were then compared for the
primary outcome of PDA requiring medical and/or surgical therapy. Secondary outcomes included multiple common neonatal morbidities.
RESULTS: 183 VLBWs were analyzed: 78 (42%) received "excess" fluids as defined while 105 (57%) were assigned to the non-excess fluid group. GA (median 27 (23-33 wk) vs. 27 (23-34 wk) and BW [850
(420-1240 g) vs. 995 (555-1245 g)] were statistically different between groups (P < 0.01). The primary outcome of PDA requiring any treatment was more common in the excess fluid group (40/78, 51%) than in the
non-excess group (35/105, 33%; P < 0.05). Secondary outcomes, including use of high-frequency ventilation [50/78 (64%) vs. 38/105 (36%)], ventilator days [median 12 (0-207 d) vs. 4 (0-171 d)], O2 days [median 68
(2-207 d) vs. 44 (0-266 d)], and BPD [56/78 (72%) vs. 55/105 (52%)] also differed between groups (all P < 0.05).
CONCLUSIONS: Excess fluid administration during the first postnatal day in VLBW neonates is associated with significant morbidity. Prospective analysis of early fluid management is needed to determine whether
fluid balance per se represents an independent risk factor for a variety of neonatal outcomes.
Filename: 753928
Presenting Author: Ankita Shukla, MD
Phone: 732 745 8523
Fax:
Title: Maximizing Nutrition To Minimize Extrauterine Growth Retardation in Low Birth Weight Neonates and Assessing Retinopathy of Prematurity in This Population
Ankita Shukla1, Bethany Jung1 and Shakuntala Chandra1. 1Division of Neonatology, Department of Pediatrics, Saint Peters University Hospital, New Brunswick, NJ.
BACKGROUND: Extrauterine growth restriction is defined as ≤10th percentile of intrauterine growth expectation based on estimated postmenstrual age in premature (23-34 weeks' estimated gestational age) neonates
at the time of discharge. Extrauterine growth retardation or post natal growth failure is attributed to low energy intake, Infection, respiratory distress, pharmacological effectsand postnatal growth lag.Low energy
intake can be improved by early provision of nutrients, early parenteral and enteral nutrition with improved overall weight gain and earlier achievement of full enteral feedingsGrowth retardation is associated with low
IgF levels which could be correlated to development of ROP Low Insulin-Like Growth Factor I (IGF-I) levels in premature infants between gestational ages of 23 and 40 weeks is a predictor of ROP. Although, we did
not measure IgF levels we analyzed to see if growth percentiles affected development of ROP in both groups.
OBJECTIVE: To reduce extra uterine growth retardation by 25 % in low birth weight infants by 2015. To assess the incidence of ROP
DESIGN/METHODS: we began starter total parenteral nutrition (TPN) within hours 2 after birth.we optimized nutrition by beginning 3.5 gms of proteins and 2 gms of lipids in infants < 1000 gms and 3 gms of lipids in
infants > 1000 gms and < 1500gms. Liquid fortifier addition to facilitate mixing instead of powder, breast milk Fortification and optimizing calories to reach 26 cal/ozWe compared 2 groups of infants after all these
interventions were implementedGroup 1All infants < 32 weeks of gestation admitted to our NICU before implementation of the guidelines group 2All infants < 32 weeks of gestation admitted to our NICU after the
implementation of the guidelinesGroups were comparable
RESULTS: reduced growth retardation from 62 to 54%. Mean discharge weight before and after intervention improved from 2356±414 gms to 2408±312 gms ( p=0.5), Length of hospital stay reduced (Mean +/-1 SD)
from 58±32 to 55±28 days (p=0.7) days to reach full feeds improved from 17±12 to 14±8 days(p=0.3), total ROP from 47% to 45% (p=0.8) and severe ROP from 11.7% to 5.3%(P=0.5)
CONCLUSIONS: Adopting the new nutritional practice guidelines helped us to reduce extra uterine growth retardation by 8% and an improving trend in Discharge weight, day of full feeds, Reduced length of NICU
stay, Showed a trend in reduction of severe ROP and total rop
Filename: 751296
Presenting Author: Qi Rong
Department/Institution/Address: Neonatal-Perinatal Medicine, MedStar Georgetown Univ Hosp, 3800 Reservoir Road, NW, Washington, DC, 20007, United States
Phone: 2024443269
Fax:
Title: Tissue Specific Expressions of IGFs Family
Qi Rong1 and Karl Pfeifer2. 1Neonatal – Perinatal Medicine, MedStar Georgetown Univ Hosp, Washington, DC and 2Section on Genomic Imprinting, NICHD/NIH, Bethesda, MD.
BACKGROUND: The insulin – like growth factors (IGFs) are known to have metabolic and growth-promoting activities that regulate embryonic, fetal and somatic tissue growth and play important roles in a variety of
human diseases.
IGF1 and IGF2 share homology with proinsulin and each peptide binds the insulin receptor (INSR), the IGF1 receptor (IGF1R) and the IGF2 receptor (IGF2R) but with varying affinities. INSR and IGF1R are
transmembrane tyrosine kinase receptors that activate intracellular signal pathways via insulin receptor substrate (IRS) proteins. IGF2R is a large transmembrane mannose-6-phosphate protein, unrelated to INSR and
IGF1R, and serves as a clearance receptor. In animal studies, IGF1 over-expressing mice are larger than normal and IGF2 knockout mice exhibit severe growth restriction with small placenta.
OBJECTIVE: We want to study the role of IGFs in fetal growth. We would like to establish a real-time PCR (QPCR) system to quantitate IGFs expression in umbilical cord blood and other human tissues.
DESIGN/METHODS: Cord blood specimens were collected and total RNA was extracted. Human liver, adipose, skeletal muscles, placenta, pancreas and fetal liver total RNA were from commercial resources. cDNA
was converted from total RNA and quantified using LightCycler 480 SYBR Green I Master on a LightCycler 480 machine. Gene expression levels were normalized to the housekeeping gene, GAPDH.
RESULTS: Gene expression levels are reported relative to their expression in adult liver (control).
IGF1 IGF1R IGF2 IGF2R
liver (control)
100 100
100 100
liver
119 97
62
adipose
950 5511
154 342
86
skeletal muscle 10
528
pancreas
64
40522 78
8
32
placenta
202 21981 3497 249
fetal liver
16
3587
cord blood
1
13753 255 692
248
2674 139
INSR-A INSR-B IRS-1 IRS-2
liver (control)
100
100
100
100
liver
101
107
26
76
adipose
504
103
137
488
skeletal muscle 60
13
7
2
pancreas
4807
980
199
300
placenta
739
118
138
238
fetal liver
226
61
155
66
cord blood
273
0
32
401
CONCLUSIONS: IGF1 is broadly expressed in most adult tissues but relatively low levels in skeletal muscle. In contrast, high level expression of IGF2 was detected in the fetus with relatively low expression in adult
tissues. INSR, IGF1R and IGF2R are widely expressed in most tissues. IRS1 and IRS2 are also easily detected in most tissue types.
We successfully established the QPCR system to study IGFs expression levels. This QPCR system was shown to be quantitative, specific and sensitive.
Our future studies will focus on the relationship of IGFs family with fetal growth.
Filename: 752378
Presenting Author: Sharadha Polam, MD
Department/Institution/Address: Department of Pediatrics - Division of Neonatology, St Peters University Hospital, 254 Easton Avenue, New Brunswick, NJ, 08901, United States
Phone: 7327357841
Fax:
Title: Decrease Incidence of Fungal Sepsis by Administration of Fluconazole To Patients <=1500 Grams
Sharadha Polam1, Ankita Shukla1, Vikas Chowdhary1 and Mark Hiatt1. 1Department of Pediatrics - Division of Neonatology, St Peters University Hospital, New Brunswick, NJ.
BACKGROUND: Invasive fungal infection is associated with substantial morbidity and mortality in preterm infants. Immature host defense mechanisms and invasive life support systems make the premature neonate
particularly susceptible to overwhelming infection. Incidence of sepsis is inversely proportional to gestational age. Invasive fungal infection occurs when fungus enters the bloodstream and invades the body. The
highest incidence of fungal infection occurs in the most extremely preterm infants - occurs in > 20% for infants < 25 weeks gestation. Fungal infection is associated with > 40% mortality, > 50% neuro-developmental
impairments, and additional hospital stay which increases cost.
OBJECTIVE: Based on conclusion drawn by Kaufman study, from December 2011, we implemented a policy of giving prophylactic fluconazole to all infants born with a birth weight of < 1500 gm Prophylaxis to begin
at birth and continue until the infant is on full feedings IV Fluconazole 3 mg/kg/day twice a week First dose to be given within 24 hours Second dose 72 hours later Then starting second week of life twice weekly. If
culture is positive, dosage is 6 mg/kg.
DESIGN/METHODS: Retrospective chart review was done on all infants < 1500, total of 110 patients. Parameters studied - Prophylaxis given or not, presence or absence of invasive fungal infection during NICU stay
and mortality.
RESULTS: Prior to implementing this policy, there were 6 fungal infections. Chi-Square = 3.973, degrees of freedom = 1, Pvalue = 0.0462. Since the implementation of the Fluconazole prophylaxis, there were no
documented fungal infections in the NICU to date. Study also showed statistically significant drop in mortality rate with a Chi-square = 4.870, degrees of freedom = 1, P value = 0.0273. Overall there is significant
decrease in mortality and fungal infection with this cohort of patients.
CONCLUSIONS: Early fluconazole prophylaxis to newborn ELBW infant is associated with decrease in fungal infection, decrease in mortality rate. Implementation of this prophylaxis regimen required constant
vigilance and education of our staff to improve compliance.
Filename: 752866
Presenting Author: Krishnaraj Mahendraraj, MD
Department/Institution/Address: Surgery, 28 Meyer Court, West Orange, New Jersey, 07052, United States
Phone: 2672887846
Fax: United States
Title: Pancreatic Cancer in the Pediatric Population: A Population Based Clinical Outcomes Study Involving 103 Patients from the Surveillance Epidemiology and End Result (SEER) Database
(1973–2010)
Krishnaraj Mahendraraj1, Christine S.M. Lau1 and Ronald S. Chamberlain1. 1Surgery, St Barnabas Medical Center, Livingston, NJ.
BACKGROUND: Primary pancreatic cancer (PPC) is rare in children and adolescents, with an incidence rate of approximately 0.018 cases per 100,000. No large patient series exists to date.
OBJECTIVE: To examine a large cohort of pediatric patients with PPC in order to determine demographic and clinical factors which determine prognosis and survival.
DESIGN/METHODS: Data on 103 pediatric PPC patients was abstracted from the SEER database (1973–2010). Pediatric patients were defined as age ≤19. Standard statistical methodology was used.
RESULTS: 103 cases of PPC were identified.
There were 8 ductal adenocarcinomas (7.8%), 5 acinar cell carcinomas (4.8%), 18 pancreatoblastomas (17.5%), 32 solid-cystic tumors (31.1%), 31 endocrine tumors (30.1%), 3 sarcomas (2.9%), and 6 unknowns
(5.8%). Overall, there were 63 females (61.2%) and 40 males (38.8%). The mean age at diagnosis was 13 years. Pancreatoblastoma was the only type more common in children age <10 (72.2%). PPC was most
common in Caucasians (50.5%), and most often well differentiated (46.7%) and size >4 cm (75.4%). All PPC most commonly present with distant disease, except for solid-cystic tumors which were more commonly
localized disease. Mean overall survival was 25.1 years, with the longest survival seen among endocrine tumors (18.9 years) and shortest in acinar cell carcinoma (5.1 years). Surgical resection was most common
(52.0%) and conferred the longest survival (33.7 ± 1.8 years). Multivariate analysis identified a survival advantage for PPC in females (OR 0.18) and surgical resection (OR 0.06), p<0.001.
CONCLUSIONS: PPC presents more often in female Caucasian children age >10 as well-differentiated tumors >4 cm at the head of the pancreas. Surgical resection is associated with significantly increased survival
benefit. All pediatric pancreatic cancer patients should be enrolled into clinical trials or registries to allow for more defined multimodality management.
Filename: 753298
Presenting Author: Sameer Farouk Sait, MD
Department/Institution/Address: 69 duke street, new brunswick, NJ, 08901, United States
Phone: 7574502028
Fax:
Title: Transfusion Related Iron Overload in Pediatric Oncology and Response To Iron Chelation Therapy
Sameer Farouk Sait1. 1Saint Peter's University Hospital, New Brunswick, NJ.
BACKGROUND: Pediatric oncology patients undergoing myelosuppressive chemotherapy require frequent pRBC transfusions. This insidious iron burden may worsen acute and chronic complications from
chemotherapy due to overlapping toxicities.
OBJECTIVE: Determine prevalence of, risk factors for, and liver toxicity associated with Transfusion Related Iron Overload (TRIO) in pediatric cancer patients, and report our experience with Iron Chelation Therapy
(ICT).
DESIGN/METHODS: A retrospective chart review of patients ≤18 years old, treated between 1/2006 and 12/2012 at Saint Peter's University Hospital with a diagnosis of acute leukemia or lymphoma was undertaken.
TRIO was defined as serum ferritin ≥1,500 ng/ml, levels were compared between patients receiving ≥10 and <10 transfusions using an unpaired, one tailed t-test (p value <0.05). Four patients with TRIO received ICT
and mean pre and post chelation ferritin levels and liver function studies were compared using a paired, one tailed t-test.
RESULTS: 36 patients were included (27 males, 9 females). Diagnoses were ALL (n=28), AML (n=3), NHL (n=3) and HL (n=2). 6 of 36 patients developed TRIO (prevalence 17%). Nineteen patients received <10 and
17 patients received ≥10 transfusions with all 6 patients with TRIO in the latter group (prevalence 37 %). Mean ± S.D of ferritin levels were 372±281 ng/ ml in patients receiving <10 transfusions and 3939±7813 ng/ml
in those receiving ≥ 10 transfusions (p value 0.05). Four patients with ferritin levels ≥ 1,500 ng/ml received ICT
Age Diagnosis No. of transfusions(10ml/kg) Pre chelation ferritin ng/ml Post chelation ferritin ng/ml Chelator used, route and schedule
19
T-cell ALL 55
4937
587
Deferiprone 500 mg PO TID
9
Pre-B ALL 23
3660
857
Deferasirox 125 mg PO QD
15
AML
30900
1960
Deferoxamine 1 g IV daily
11
T-cell ALL 20
7310
685
Deferasirox 125 mg PO QD
38
and had statistically significant reductions in ferritin, ALT, alkaline phosphatase and bilirubin levels after treatment
Pre ICT
Post ICT
P value
Ferritin (mean ± SD)
11635 ± 12935 787 ± 848 0.09
ALT (mean ± SD)
599 ± 326
24 ± 6.5
0.02
ALP (mean ± SD)
786 ± 515
76 ± 13
0.04
Total Bili6 (mean ± SD)
3.8 ± 1.8
0.2 ± 0.15 0.01
.
CONCLUSIONS: ICT reduces ferritin and may improve liver function in patients with TRIO. Further studies are warranted to evaluate the safety, efficacy, mode of administration of ICT and develop guidelines for
screening and treatment of TRIO in pediatric oncology.
Filename: 756164
Presenting Author: Shubhi Kaushik, MD
Department/Institution/Address: Pediatrics, 451 Clarkson Avenue, Brooklyn, NY, 11203, United States
Phone: 347-901-3007
Fax:
Title: Clinical Profile of Children with Sickle Cell Disease (SCD) & Abdominal Pain : Delayed/Missed Acute Surgical Abdomen?
Shubhi Kaushik1, Nitya Gulati1, Alitia Kandasamy1, Scott T. Miller2 and Ninad Desai2. 1Pediatrics, Kings County Hospital Center, NY, NY and 2Pediatric Hematology, Kings County Hospital Center, NY, NY.
BACKGROUND: 10% of patients with SCD & VOC admitted each year have abdominal pain. Assuming vaso-occlusive crises (VOC) as the underlying cause of abdominal pain leads to a delay in diagnosis of an acute
surgical abdomen.
OBJECTIVE: To profile the clinical picture of children hospitalized with SCD & abdominal pain to assess the incidence of acute surgical abdomen in these patients & compare the differences in presentation and
clinical course with the more common diagnosis of VOC.
DESIGN/METHODS: A retrospective chart review (Jan 2009-Oct 2012 ; 4 years) was done for pediatric patients with SCD admitted to our hospital.
RESULTS: 38 patients were reviewed for 59 inpatient admissions,all patients presented with chief complaint of abdominal pain. Age range: 4 to 19 yrs. Of 38 patients: HBSS -33, HbSC -3 and HBSbetathal-2. The
most common initial diagnosis for admission was VOC : 46 ( 46/59,77%) and Cholelithiasis:5 (5/59,8.4%) Other diagnoses: 8(8/59,13.5%). In 11 out of 46 admissions with initial diagnosis of VOC patient developed
ACS (11/46, 23%) and in 3 out of 46 admissions with initial diagnosis of VOC patient required surgery (3/46,6.5%). Dx at Discharge : VOC (31/59, 52%), VOC and ACS ( 11/59, 18. 6%), Cholelithiasis
/Cholecystitis(7/59, 11.8%), UTI (3 /59,5%), Appendicitis (2/59,3.3%) & Others 5(5/59,8.4 %). Mean peak WBC and Tmax in 3 pts with Ac Surgical Abd were 19.08 & 102.1,& were not significantly different compared
to pts with VOC.
Pt Age Sex Pain Location Tmax Initial Dx Discharge Dx
Sx
1 14y M
Epigastric
102.4 VOC
Ac. Appendicitis Lap. Appendectomy
2 16y F
Diffuse
102.9 VOC
Ac. Appendicitis Appendectomy
3 14y M
Diffuse
101.2 VOC
Cholelithiasis
Lap.Cholecystectomy
CONCLUSIONS: Clinicians consider Ac.surgical abd. emergencies on a lower diagnostic priority in children with SCD because they do not present with the traditional findings of a “surgical” abdomen. Common but
important clinical clues such as WBC count and Peak of temperature do not aid the clinician in differentiating patients with Ac. abdomen. Our review highlights cases of appendicitis and cholecystitis disguised as
abdominal VOC. We thus suggest that clinicians institute early, aggressive imaging with USG or CT and repeat imagining within 24 hours, to rule out an Ac. Surgical abdomen in patients presenting with atypical or
prolonged abdominal pain.
Filename: 755690
Presenting Author: Christine S.M. Lau, MD
Department/Institution/Address: Surgery, St Barnabas Medical Center, 94 Old Short Hills Road, Livingston, New Jersey, 07039, United States
Phone: 9733225000
Fax:
Title: Chordomas in the Pediatric Population: A Population Based Clinical Outcomes Study Involving 86 Patients from the Surveillance Epidemiology and End Result (SEER) Database (1973–2010)
Christine S.M. Lau1, Krishnaraj Mahendraraj1 and Ronald S. Chamberlain1. 1Surgery, St Barnabas Medical Center, Livingston, NJ.
BACKGROUND: Primary chordomas (PC) are rare cancers arising from the notochord remnants primarily affecting adults. It is extremely rare in the pediatric population with the current literature limited to a few case
reports.
OBJECTIVE: To examine a large cohort of pediatric PC patients in order to determine clinical, and pathologic factors which impact prognosis and survival.
DESIGN/METHODS: Data on 1,358 patients was abstracted from the SEER database (1973–2010). Pediatric patients were defined as age ≤19. Standard statistical methodology was used.
RESULTS: Among 1,358 patients with PC, 86 (6.3%) were pediatric (mean age 12).
PCs were more common among males in both pediatric (58.1%) and adult populations (58.8%). PCs were also more common among Caucasians in both groups (61.6% vs. 78.5%); however significantly more
Hispanic (18.6% vs. 11.0%) and Asian/Pacific Islander children (14.0% vs. 7.7%) were affected,p<0.001. More pediatric PCs were located cranial and fewer were sacral. Despite a majority of PC being locoregional,
more pediatric patients presented with distant disease and lymph node involvement. Fewer pediatric PCs were >4cm. Surgery was the most common treatment in both groups (51.2% vs. 45.5%). Survival in pediatric
PC patients undergoing surgery was significantly longer than in adults (22.5 vs. 14.4 years),p<0.001. Cancer-specific mortality was higher for pediatric PC (37.6% vs. 36.4%),p<0.001. Multivariate analysis identified
distant disease (OR 20.3), Hispanic (OR 7.2) and Asian/Pacific Islander race (OR 8.4) as risk factors for increased mortality.
CONCLUSIONS: PCs are rare in the pediatric population, presenting most often as tumors >2cm in the cranium of male Caucasians. Pediatric PC exhibits a higher rate of metastatic disease and a higher
cancer-specific mortality than adults. Surgical resection significantly improves survival in pediatric PC, and should be considered as first line therapy in all eligible children.
Filename: 753808
Presenting Author: Hartmut M. Hanauske-Abel, MD PhD
Department/Institution/Address: 185 S. Orange Avenue, Newark, NJ, 07103, United States
Phone: 201-921-9325
Fax: 201-567-0169
Title: Genetic Elements Common To HIV-1, Ebola, and Marburg: Proline Clusters (ProCls) As Targets for a Novel Class of Broad-Spectrum Antivirals Impervious To Escape Mutations
Hartmut M. Hanauske-Abel1, Michael Spino2, Mainul Hoque3, Anthony Popowicz4, George K. Lee4, Darlene D'Alliessi Gandolfi5 and Paul E. Palumbo6. 1Pediatrics, Rutgers NJMS, Newark, NJ; 2Pharmacy, University of
Toronto; and ApoPharma, Weston, ON, Canada; 3Microbiology, Biochemistry and Molecular Genetics, Rutgers NJMS, Newark, NJ; 4Information Technology, Rockefeller University, New York, NY; 5Chemistry,
Manhattanville College, Purchase, NY and 6Infectious Diseases and International Health, Geisel School of Medicine at Dartmouth, Lebanon, NH.
BACKGROUND: The side chain of the amino acid proline [P] links to and deactivates its α-amino group, slowing peptide synthesis, and also limits flexibility of ([P]n , n≥2) and ([PxP], x≤2) ProCls. They determine
protein interactions, but at the ribosome jam the nascent-peptide exit tunnel and stop translation. To rescue translation, eukaryotes employ eIF5A, which contains hypusine, a residue requiring molecular
oxygen-dependent hydroxylation. Over 85% of HIV-1 genes encode such ProCls.
OBJECTIVE: To test the hypothesis that ProCls predominance allows for i.) a general classification of viruses; and ii.) the discovery of antiviral eIF5A hydroxylation inhibitors (eIF5A-HIs) that cause translational
stalling of ProCls-rich proteins, preferentially disrupting viral, but not host biology.
DESIGN/METHODS: Advanced computational and experimental methods, sequence-guided re-examination of protein data.
RESULTS: HIV-1 encodes 28 ProCls in 8 of its 9 genes; Ebola encodes 34 ProCls in 7 of its 7 genes; and Marburg encodes 35 ProCls in 6 of its 7 genes; by contrast, Influenza A encodes 14 ProCls in 7 of its 8
genes. Using hydroxypyridinones (HOPOs) as established eIF5A-HIs, all ProCls-containing HIV proteins tested so far – Rev, Tat, and Gag / p24 – were suppressed in HIV-infected cell lines and primary cells, whereas
the ProCls-lacking pro-apoptotic HIV protein Vpr was not. In HOPO-exposed HIV-infected cells, GAPDH mRNA (no ProCls) remained on host polysomes; β-actin mRNA (2 ProCls) decreased on host polysomes; HIV
Gag mRNA (5 ProCls) disappeared from host polysomes. A Phase I clinical trial testing a HOPO pioneer drug revealed HIV RNA decline on-drug that off-drug did not rebound for a period of over 670 times the drug's
half-life.
CONCLUSIONS: Our HIV-1 results indicate that inhibitors of host eIF5A hydroxylation disrupt viral protein synthesis, revealing differential virus-vs-host susceptibility to eIF5A-HIs. This offers a mechanistic,
gene-based explanation for the reported apoptotic suicide of HIV-infected HOPO-exposed cells, previously identified as an avenue towards a 'cure of HIV-AIDS' (HMHA et al., PLOS ONE 8 : e74414; 2013). The
multiplicity and the crucial functions of viral ProCls defeat viral escape mutations. Synthesis of optimized agents and studies of Ebola / Marburg models should be initiated.
Filename: 754483
Presenting Author: Shetal Shah, MD FAAP
Department/Institution/Address: Pediatrics, Maria Fareri Children's Hospital/ New York Medical College, 100 Woods Road,C-225A, Valhalla, NEW YORK, 10595, United States
Phone: 917-940-2262
Fax:
Title: Expansion of Tetanus, Diptheria and Acellular Pertussis (Tdap) Vaccination Guidelines Is Associated with Reduction in Infant Pertussis Hospitalization Rates
Shetal Shah1, Nandini Vijayakanthi2 and Heather L. Brumberg1. 1Pediatrics, Maria Fareri Children's Hospital/ New York Medical College, Valhalla, NY and 2Pediatrics, Maimonides Medical Center, Brooklyn, NY.
BACKGROUND: Pertussis has increased in the last decade, causing significant morbidity & mortality in young infants. Immunization with Tetanus, Diptheria & Acellular Pertussis (Tdap) vaccine provides immunity. In
2005, guidelines for Tdap added adolescents, & in 2008, recommendations expanded to include postpartum caregivers to promote cocoon immunity. The impact of these guidelines on rates of pertussis hospitalization
has not been fully studied.
OBJECTIVE: To determine the association of expanded Tdap immunization guidelines on pertussis hospitalization in children 0-2 months, 0-5 months & 0-12 months of age.
DESIGN/METHODS: Data on pertussis cases were extracted by International Classification of Disease, Revision-9 code from the nationwide Kids' Inpatient Database from the Agency for Healthcare Research &
Quality & national Healthcare Cost and Utilization Project. Data on age, length of hospital stay, hospital charges & mortality were extracted for the years 2000, 2003, 2006 & 2009. Chi-square and t-tests were done
and p<0.05 was significant. Comparisons were made year-to-year and pre/post 2005.
RESULTS: During the study period, 12,085 total cases of pertussis were identified (25.5% in 2000, 25.1% in 2003, 22.6% in 2006 & 26.7% in 2009. Comparing pre/post 2005, reductions in inpatient pertussis cases
were seen for patients 0-2 months (49.3% vs. 46.3%, p<0.001), 0-5 months (65.3% vs. 61.1%, p<0.0001) & 0-12 months (69.1% vs. 65.3%, p<0.001). The percentage of inpatient cases occurring in children 0-2
months decreased from 2006 to 2009 -- after introduction of the postpartum Tdap guideline (48.1% vs. 44.7%, p<0.01). This recommendation was associated with reductions in the 0-5 month (64.1% vs. 58.6%,
p<0.0001) and 0-12 month (68.1% vs. 62.9%, p<0.0001) age ranges over the same time period. Average length of stay for all patients reduced significantly between 2003 and 2006 (6.16+8.0 vs. 5.71+8.2, p<0.035)
but did not significantly reduce hospital charges (p<0.197). Length of stay increased from 2006 to 2009 (p<0.004) and was associated with increased charges (p<0.001). No difference was seen in the percentage of
0-2 month, 0-5 month or 0-12 month pertussis admissions between 2003 and 2006, when the adolescent guideline was introduced.
CONCLUSIONS: Measures to promote cocoon immunity were associated with reduced pertussis hospitalization throughout the first year of life.
Filename: 750438
Presenting Author: Mark D. Hicar, MD, PhD
Department/Institution/Address: Pediatrics, Women and Children's Hospital of Buffalo, 239 Bryant Street, Buffalo, NY, 14222, United States
Phone: 1-716-878-7300
Fax:
Title: Antibodies Targeting Structural Epitopes on gp41 as a Potential Inherent Resistance Mechanism To HIV Fusion Inhibitors
Hakimuddin Sojar1, Michele Smith1, Ravikumar Aalinkeel2, Supriya Mahajan2, Stanley A. Schwartz2, Chiu-Bin Hsiao3 and Mark D. Hicar1. 1Pediatrics, Kaleida Heatlh and Women and Children's Hospital of Buffalo,
University at Buffalo, Buffalo, NY; 2Division of Allergy Immunology and Rheumatology, Department of Medicine, Kaleida Health, Buffalo General Hospital, University at Buffalo, Buffalo, NY and 3Temple University
School of Medicine, Allegheny General Hospital, Pittsburgh, PA.
BACKGROUND: The functional viral envelope glycoprotein spike of HIV is a trimeric structure composed of three heterodimers of gp120 and gp41 proteins. When the receptor-binding domain of gp120 interacts with
the CD4 receptor, it induces a conformational change in the heterotrimer that fuses the viral envelope membrane to the target cell. During this event, the gp41 portion of the trimer folds in on itself juxtaposing the gp41
helical Heptad repeat one and two domains of each monomer to form a six helical bundle. One of the newest class of therapies against HIV are termed fusion inhibitors. These inhibitors, such as T20 or envurfitide, are
amino acids analogs of the gp41 heptad repeat 2 region and interfere with gp41 six helical bundle formation. A large proportion of those that fail this therapy show no genetic mutations to explain regimen failure.
Recent evidence show that, in vitro, certain antibodies can interfere with the effect of fusion inhibitors.
OBJECTIVE: Our lab has previously created trimer conformation specific antibodies that target two different structurally influenced epitopes in gp41. We hypothesize that antibodies targeting the structural epitopes of
the six helical bundle may 'lock-in' this formation and interfere with fusion inhibitors.
DESIGN/METHODS: Here we established an assay to assess functional interference with T20 fusion inhibition. Hela cells expressing surface CD4 and CHO cells with stably expressed HIV-1 HXB2 envelope were
obtained from the NIH AIDS reagents repository. These cells form syncytium when mixed, and T20 can block this syncytium formation. T20 was added to HeLa and CHO cell mixes in the presence of a panel of
antibodies to assess fusion inhibitor interference of antibodies. We obtained serum from a group of HIV subjects through IRB approved studies to assess the population prevalence of these antibodies. Utilizing an
ELISA format, we performed serum competition with biotinylated antibodies.
RESULTS: Antibodies targeting two gp41 conformational epitopes interfere with T20 fusion inhibition. In preliminary serum results, these epitopes are not uncommonly targeted. Antibody responses against these
epitopes are more prevalent in Long-term non-progressors versus normal progressors.
CONCLUSIONS: Antibodies targeting structural epitopes of gp41 are not uncommon and may interfere with fusion inhibitor therapies.
Filename: 752510
Presenting Author: Sabina D. Holland, MD
Department/Institution/Address: Pediatric Infectious Disease, Hasbro Children's Hospital, 593 Eddy Street, POB 018, Providence, RI, 02860, United States
Phone: 401-444-8360
Fax: 401-444-5650
Title: Impact of Rotavirus Vaccination on Circulating Rotavirus Genotypes in a State With a Universal Vaccine Policy
Sabina D. Holland1, Sara M. Nelson1 and Penelope Dennehy1. 1Pediatric Infectious Disease, Hasbro Children's Hospital, Providence, RI.
BACKGROUND: Rhode Island (RI) has a universal vaccine policy. Rotavirus (RV) vaccine coverage in RI is estimated to be 84.4% in 2013. The use of a single RV vaccine and RI's high vaccination rate provide an
opportunity to study effect of vaccination on circulating RV genotypes. In RI, prior to the introduction of RV vaccine, G1 was the prevalent genotype. From 2006-2009, children received RV5. In 2010, RV1 became the
RV vaccine provided.
OBJECTIVE: The aim of the study is to characterize circulating rotavirus genotypes before and after implementation of RV vaccine in RI.
DESIGN/METHODS: Cases were identified using active hospital based surveillance of patients aged <10 admitted to Hasbro Children's Hospital with gastroenteritis from 1/1/02 to 12/31/12. From 2012 to 2014, cases
were identified if a stool sample was sent for RV testing. Stool samples were tested for RV using a commercially available EIA. Viral RNA was extracted and VP7 genotyping was performed using semi-nested Reverse
Transcription PCR for primers specific for G1, G2, G3, G4, and G9.
RESULTS: Of 835 RV + stools, 756 (91%) were available for genotyping. Of those, 54 (7%) were nontypeable (NT). Implementation of RV vaccine decreased the number of RV cases/year from a mean of 127.5
(pre-vaccine) to 1 in 2014. G1 was the predominant genotype in all but 1 year prior to RV introduction. G1 remained the predominant genotype for several years following introduction of RV5 in 2006 (87%, 70%, 84%,
38%). After the introduction of RV1 in 2010, the predominant genotype was G2 (90%). Thereafter, the predominant type is NT. Sequencing of NT strains is ongoing; of those sequenced all are G12.
CONCLUSIONS: RV vaccination decreased RV disease in RI. G1 was the prevalent genotype in RI prior to RV vaccine introduction and after implementation of RV5. Variation in genotype distribution occurred only
after adoption of RV1. Further studies are needed to determine if this change is secondary vaccine induced immune pressure or due to natural variation.
Filename: 750781
Presenting Author: Laura M. Wiltsie, D.O.
Department/Institution/Address: 219 Bryant St, Buffalo, NY, 14222, United States
Phone: 716-207-1562
Fax:
Title: Paragonimus Westermani Infection Masking As Recalcitrant Multi-Drug Resistant Tuberculosis
Laura M. Wiltsie1, Adam J. Olewnik1 and Mark D. Hicar1. 1Pediatrics, Women and Children's Hospital of Buffalo, Buffalo, NY.
BACKGROUND: Over a million Southeast Asian refugees came to the United States since 1975. Paragonimus westermani is endemic in Southeast Asian and presents similar to tuberculosis.
OBJECTIVE: To highlight the need for clinicians to reexamine diagnoses of Tuberculosis that are atypical for the normal course of pediatric tuberculosis.
DESIGN/METHODS: We present a case of paragonimiasis in a Malaysian child previously diagnosed with tuberculosis presenting with cavitary lung lesions and suspected meningitis.
RESULTS: A recently immigrated 11 year-old female previously diagnosed with tuberculosis was admitted for headache, stiff neck, and backpain. She was diagnosed in Myanmar at one year of life when she
developed hemoptysis and a right upper lobe cavitary lesion. At age 7, she had a generalized tonic clonic seizure and was treated for multi-drug resistant tuberculosis. Radiographs continued to show evidence of lung
disease despite prolonged therapy and multiple negative cultures. On examination, she was lethargic, photophobic, with meningeal signs, and decreased right lung aeration. Significant presenting labs showed 3550
CSF white blood cells/mm3 and 7% blood eosinophils. A chest radiograph revealed multiple cavitating pulmonary lesions with hilar adenopathy. Brain MRI revealed right frontal and left parietal calcifications and a left
ventricular hemorrhage with mild rim enhancement but no meningeal enhancement. Tuberculin skin test, interferon gamma release assay, sputum stains and mycobacterial cultures were negative. Stool evaluation
revealed Paragonimus westermani and serum antibody testing was positive. She was treated with Praziquantel and remained well without hemoptysis at one-year follow-up.
CONCLUSIONS: Paragonimus westermani can be an overlooked cause of pulmonary disease in children from Southeast Asia. Recurrent hemoptysis, CNS lesions, and eosinophilia in a patient from an endemic
region should alert the physician to Paragonimus westermani, especially in children with “adult-type” tuberculosis symptoms.
Filename: 756380
Presenting Author: Paul K. Sue, MDCM
Department/Institution/Address: 126 North Rose Street, Baltimore, MD, 21224, United States
Phone: 347-306-9547
Fax:
Title: Characteristics of Invasive Cytomegalovirus (CMV) Enterocolitis in Immunocompetent Children
Paul K. Sue1, Nicole Salazar-Austin2 and Ravit Arav-Boger3. 1Pediatric Infectious Diseases, UT Southwestern, Dallas, TX and 2Pediatric Infectious Diseases, Johns Hopkins University, Baltimore, MD.
BACKGROUND: Cytomegalovirus (CMV) infection is a major source of morbidity and mortality among congenitally infected and immunocompromised individuals. However, among immunocompetent children, CMV
colitis has rarely been reported.
OBJECTIVE: We reviewed the literature as well as our own recent clinical experience in order to identify and characterize cases of invasive CMV infection among immune competent children.
DESIGN/METHODS: We performed a literature search in Medline using PubMed to identify cases of CMV colitis reported among immune competent children, utilizing the search terms “cytomegalovirus,”
“immunocompetent,” “colitis,” “infection,” “pediatric” and “children.” Articles were reviewed, cross referenced, and cases included if individuals were less than 18 years of age, demonstrated documented evidence of
CMV infection by histology or PCR, and had clinical symptoms. Exclusion criteria were prematurity, confirmed congenital CMV infection, concordant treatment with immunosuppressive therapy, or identified underlying
immunodeficiency. Individual case data, including age, gender, birth weight, gestational age at birth, diet, white blood cell count at presentation, and immunologic workup were collected and analyzed to characterize
salient features of this cohort.
RESULTS: We identified 20 cases of invasive CMV among immune competent individuals in the literature, as well as two additional previously unreported cases at our institution. Median age at presentation was 2.5
months (IQR 2.0,7.0), with 18/21 (86%) of affected individuals, male. Median birth weight was 3350g (3000, 3700), and 13/18 individuals (72%) were breast fed at presentation. Median WBC at presentation was
16.4x103 cells/µL (9.6x103, 20.2x103), with bloody diarrhea noted in 8/20 (42%) individuals. Thrombocytosis (platelet count> 140,000/µL) was observed in 11/18 (61%) of individuals. Twelve individuals (54%) received
antiviral therapy. Two (9%) suffered serious complications (perforation, stricture), but all others fully recovered. No underlying immunodeficiency was identified in any case.
CONCLUSIONS: While considered a rare cause of colitis among immune competent individuals, invasive CMV infection should be considered in cases of intractable diarrhea in young children. Specifically, male,
breastfed infants less than 3 months of age who present with thrombocytosis in the context of diarrhea may be at increased risk for invasive gastrointestinal CMV disease.
Filename: 751604
Presenting Author: Jonathan Beus, MD, MS
Department/Institution/Address: Division of Infectious Diseases, The Children's Hospital of Philadelphia, 3535 Market Street, Philadelphia, PA, 19104, United States
Phone: 404-374-5710
Fax:
Title: The Effect of a Clinical Pathway on Antibiotic Prescribing for Outpatient UTI
Jonathan Beus1, Carter Cowden1, Talene Metjian2, Daniele Dona1, Ron Keren3,4, Jane Lavelle5, Aileen Schast4, Kathy Shaw5 and Jeffrey Gerber1. 1Division of Infectious Diseases, The Children's Hospital of
Philadelphia, Philadelphia, PA; 2Antimicrobial Stewardship Program, The Children's Hospital of Philadelphia, Philadelphia, PA; 3Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA;
4
Office of Clinical Quality Improvement, The Children's Hospital of Philadelphia, Philadelphia, PA and 5Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Clinical pathways aim to standardize clinical practice. In 1/2011, our institution released a pathway for care of outpatient pediatric urinary tract infection (UTI) that recommended cephalexin as first-line
therapy for most children. Targeted education was provided only in the emergency department, but the pathway was made available on the hospital's website.
OBJECTIVE: To determine whether release of a clinical pathway without directed education resulted in practice change.
DESIGN/METHODS: This was a retrospective, time series study of outpatients, 2 mo-11 yr, who had leukocyte esterase present and a positive urine culture (1/2005-9/2013). Data were obtained electronically,
excluding patients with recent antibiotic exposure, polymicrobial urine cultures, and practices not present before and after pathway release. Trends were assessed with a longitudinal, logistic marginal model, clustered
on practice, and standardized by patient race, age, and insurance type. Longitudinal terms were allowed to vary by practice type, before and after pathway release.
RESULTS: There were 2910 children eligible for inclusion. Prior to the pathway, cephalexin use was lowest in the non-academic practices (p = 0.03) and increasing in the ED and academic practices only (p<0.001).
The pathway resulted in an increase in cephalexin use for academic practices (p=0.001) and the ED (p<0.001), but not non-academic practices (p=0.564). After pathway release, all groups had similar rates of
increase over time.
CONCLUSIONS: Prior to pathway implementation, non-academic sites had the lowest rates of cephalexin use for UTI and were the only practice type with non-increasing rates. While pathway release did not
immediately shift use in these practices, adherence increased over time. Clinical pathways may reduce variations in care across practices, but effective implementation may require targeted education.
Filename: 755360
Presenting Author: Namrita J. Odackal, DO
Department/Institution/Address: Pediatrics, Maria Fareri Children's Hospital, New York Medical College, 100 Woods Road, Valhalla, NY, United States
Phone: 914.493.5634
Fax:
Title: Risk of Bacterial Meningitis in Young Infants and the Role of Lumbar Puncture for Evaluation of Fever
Namrita J. Odackal1, Andrew Lim2, Simon Li1, Sheila M. Nolan1 and Aalok R. Singh1. 1Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY and 2New York Medical College, Valhalla, NY.
BACKGROUND: Current recommendations to evaluate febrile infants < 30 days old for serious bacterial infection (SBI) include obtaining blood, urine and cerebrospinal fluid (CSF) cultures. This standard was
established prior to routine use of antepartum ampicillin for Group B Streptococcus (GBS) carriers and prior to the 13-valent pneumococcal conjugate vaccine. Both have decreased the incidence of GBS and
pneumococcal meningitis. The evaluation of fever has further evolved with the advent of rapid viral diagnostic tests.
OBJECTIVE: Given the changes in epidemiology and assessment of the febrile young infant, our research goal is to define criteria for risk stratification and limit the necessity for invasive testing. This pilot study
describes the epidemiology of previously healthy term febrile infants < 30 days old and test characteristics of their lumbar puncture (LP).
DESIGN/METHODS: This was a retrospective study of previously healthy infants 3 to 30 days old who presented to Maria Fareri Children's Hospital with a fever from August 2010 to June 2014 whose evaluations
included LP identified by laboratory database. Subject clinical characteristics and laboratory data were collected.
RESULTS: 642 infants were identified, 35 infants had a positive CSF bacterial culture. 19 were excluded due to evaluation at < 3 days of life (2), birth at < 37 weeks gestational age or history of chronic medical
condition (16), and lab error (1). Thirteen cases were culture contaminants based on clinical assessment by chart review. 3 cases had bacterial meningitis, 2 of which had concurrent upper respiratory infections (URI)
due to RSV (Table).
Table: Epidemiology of cases of bacterial meningitis in term previously
healthy infants 3-30 days
Case # Age (days) CSF culture Blood Culture Urine Culture Viral test
1
27
GBS
-
RSV
2
13
Enterococcus -
GBS
-
RSV
3
7
GBS
GBS
-
GBS
CONCLUSIONS: In our cohort we found that the rate of bacterial meningitis for febrile infants 3 to 30 days is 0.5% (3/642). Our data indicates that despite known reductions in GBS and pneumococcal meningitis, even
given an alternative diagnosis (bacteremia, urinary tract infection, viral URI), it is difficult to risk stratify young infants for evaluation by LP. Due to the low rate of bacterial meningitis in the population of interest, further
study using a multicenter strategy and additional biomarkers is required to assess for potential methods to risk stratify these patients.
Filename: 755846
Presenting Author: Daniel Ruderfer, MD
Department/Institution/Address: Pediatrics, Winthrop University Hospital, 259 FIrst ST., Mineola, New York, 11501, United States
Phone: 5166639414
Fax: 516 663-3793
Title: Enterovirus D68 Infection in Children: Is It As Severe As Initially Described?
Daniel Ruderfer1 and Leonard R. Krilov1,2. 1Pediatrics, Childrens Medical Center; Winthrop University Hospital, Mineola, NY and 2Pediatrics, State University of New York Stony Brook School of Medicine, Stony Brook,
NY.
BACKGROUND: In August 2014 an increase in severe respiratory illness in children associated with infection with enterovirus D68 (EV-D68) was described in hospitals in Kansas City, MO and Chicago, IL.
Subsequently 1,116 cases have been detected in 47 states and the District of Columbia as of November 6, 2014 per the CDC.
OBJECTIVE: To report on the 4 cases of confirmed EV-D68 infection admitted to our pediatric service.
DESIGN/METHODS: Testing for EV-D68 consisted of a screening nasopharyngeal sample tested by multiplex PCR. If the PCR was positive for rhinovirus/enterovirus additional testing through the New York State
Dept. of Health could be requested which would first test for enterovirus RNA. If that assay was positive, specific enterovirus typing for EV-D68 was performed by RT-PCR and dideoxysequencing.
There were no specific indications for testing; rather they were ordered at the discretion of the attending physician.
Four of 11 specimens sent from Sept. 9 to Oct. 6, 2014 were positive for EV-D68.
RESULTS: The 4 children diagnosed with EV-D68 ranged in age from 4.33 to 9.25 yrs and all had a prior history of wheezing or asthma with 3 of the 4 on controller medications prior to admission. In all 4 cases onset
of illness was acute (~1 day) and admission diagnosis was status asthmaticus. All were treated with bronchodilators and steroids. Two received supplemental oxygen for <1 day. Two were admitted to the PICU for
initial monitoring but remained there <24 hrs.
Chest x-rays were performed in 3 of the 4 cases; all 3 revealed mild prominence of interstitial markings with 1 also noted to have left lower lobe infiltrate vs. atelectasis. One child received amoxicllin for a (+) rapid
strep test; the other 3 did not receive antibiotics.
All of the children did well and were discharged in 1 to 3 days. No cases with focal neurological symptoms were detected.
The time from obtaining the specimen to EV-D68 diagnosis ranged from 8 to 19 days. The mean age for all rhinovirus/enterovirus specimens at our center was 39.4 mos (+/- 42.4). We have not seen an increase in
inpatient or ICU admissions for asthma over last year.
CONCLUSIONS: Our 4 cases of EV-D68 infection are consistent with earlier reports in terms of age, rapid onset of respiratory symptoms, and history of underlying asthma. However we did not observe increasingly
severe disease at our institution. Further systematic, prospective studies are needed to gain a better understanding of the spectrum of illness caused by this agent.
Filename: 752572
Presenting Author: Amy J. Sloane, MD, MHS
Department/Institution/Address: Nemours/ AI Dupont Hospital for Children, 1600 Rockland Rd., Housestaff Office, Wilmington, DE, 19803, United States
Phone: 302-932-2594
Fax:
Title: Culture Pus Not Blood: An Intervention To Minimize Lab Testing in the Evaluation of Uncomplicated Skin and Soft Tissue Infections
Amy J. Sloane1 and David M. Pressel1. 1Nemours/AI DuPont Hospital for Children, Wilmington, DE.
BACKGROUND: Blood cultures and CBCs are commonly used in evaluating pediatric patients presenting to the Emergency Department with skin and soft tissue infections (SSTIs). However, published data have
repeatedly shown that these studies may not aid in patient management and may in fact result in false positive (contaminated) cultures, increased hospital charges, and possibly increased length of stay and antibiotic
treatment.
OBJECTIVE: To identify whether a joint quality improvement project between our Emergency Department and Hospital Medicine staff can decrease the collection of blood tests in healthy children with uncomplicated
SSTIs.
DESIGN/METHODS: This longitudinal cohort study used modified famous posters to discourage the use of routine lab studies in healthy children being evaluated for uncomplicated SSTIs. Posters were prominently
displayed in work stations to urge staff not to obtain blood cultures for these patients. A retrospective EMR chart review was performed. Patients eligible included otherwise healthy children admitted to a free-standing
children's hospital. Patients were excluded if they were age <2 months, had an underlying diagnosis of immune deficiency, cancer, indwelling hardware, surgical site infection, bite wound, or concern for significant
other disease process.
RESULTS: Data was collected for 230 patients. Patients in the 3 cohorts were similar in terms of clinical characteristics. Compared to baseline, posters discouraging routine lab testing decreased blood cultures (47%
to 17%, P=0.001) and CBCs (53% to 36%, P=0.03). This effect partially persisted after poster removal for blood cultures (27%, P=0.02) and CBCs (42%, P=0.14). There was no change in mean length of stay. Seven
day readmission rates increased in the poster cohort (0% to 7%, P=0.02) without clear relation to lab testing, but not in the follow up cohort (3%, P=0.1). No blood cultures were positive in any cohort.
CONCLUSIONS: A simple and creative poster campaign can improve staff laboratory testing practices.
Filename: 750825
Presenting Author: Poorva Vaidya, B.S.
Department/Institution/Address: 1718 37th ST NW, Washington, DC, 20007, United States
Phone: 9493518539
Fax: 9493518539
Title: Changes in Cortical Structure in Infantile Nephropathic Cystinosis
Poorva Vaidya1, Timothy T. Brown2 and Doris A. Trauner2,3. 1Georgetown University School of Medicine, Washington, DC; 2Neurosciences, University of California, San Diego, La Jolla, CA and 3Rady Children's
Hospital San Diego, San Diego, CA.
BACKGROUND: An autosomal recessive lysosomal storage disease, infantile nephropathic cystinosis is associated with cerebral atrophy and impairments in visuospatial processing. However, the neuroanatomical
basis of visuospatial impairments in cystinosis patients has yet to be fully characterized.
OBJECTIVE: To study the cortical neurobiology of cystinosis patients aged 3-12 and its relationship to visuospatial performance.
DESIGN/METHODS: FreeSurfer-based analysis of MRI scans acquired in 34 children with cystinosis aged 3-12 years and 34 typically-developing counterparts was used to compare cortical thickness in
neuroanatomical regions associated with visuospatial functioning. Woodcock-Johnson Spatial Relations test scores were also compared between the two groups.
RESULTS: Regions associated with the visuospatial cortex were found to have significantly diminished cortical thickness in cystinosis patients than control subjects (p<0.05) Cortical thickness measures in some
regions of interest in the control group showed a moderate negative correlation with standard scores on the Woodcock-Johnson Spatial Relations test, while cortical thickness measures in cystinosis patients showed
dissociation with visuospatial processing.
CONCLUSIONS: This study provides new information that cystinosis patients exhibit unique cortical morphology compared with healthy controls, which may contribute to commonly observed cognitive impairments.
Our findings may suggest a neuroanatomical basis for visuospatial deficits in cystinosis patients.
Filename: 755962
Presenting Author: M. Mariappan, MBBS
Department/Institution/Address: Pediatrics, Cooper Chirldren's Regional Hospital, 1 Cooper Plaza, Camden, NJ, 08103, United States
Phone: 8563422265
Fax:
Is Presenting Author a Trainee? Yes, Other - Applying for residency
Title: Long Term Neuroprotective Effects of Human Adipose-Derived Stem Cells (hASCs) and Hypothermia in Neonatal Rats Post Hypoxic Ischemic Encephalopathy
A. Kushnir1, M. Mariappan1, A. Koolwal1, N. Kappy2 and M. February3. 1Pediatrics, Cooper Children's Regional Hospital, Camden, NJ; 2Surgery, Cooper Medical Center, Camden, NJ and 3Pediatrics, Rutgers RWJ
Medical School, New Brunswick, NJ.
BACKGROUND: Hypoxic ischemic encephalopathy (HIE) continues to be a major cause of morbidity and mortality in the neonatal population. Current standard-of-care is hypothermia (HT), which is neuroprotective
against HIE in the neonatal brain. Recent research using bone marrow derived mesenchymal cells (BMMSCs) has shown them to have neuroprotective effects in animal models of HIE. Human derived adipose stem
cells (hASCs) share all the properties of BMMSCs, while easier to harvest and are more resistant to donor co-morbidities.
OBJECTIVE: To determine whether neuroprotection with hASC added to HT therapy will be greater than with HT alone in the term neonatal HIE rat.
DESIGN/METHODS: Seven day old Sprague Dawley (SD) rats were subjected to left carotid artery ligation or isolation alone in shams. After 2 hours of recuperation the ligation group was subjected to hypoxia with
8% oxygen/92% nitrogen for 120 minutes. Half the rats will receive the standard-of-care (HT) and IV injection of hASCs and half will receive HT and normal saline (NS) only. Injections were performed 48 hours after
surgery via tail vein. Rota-rod and cylinder tests were used to assess skill learning, balance, co-ordination, and symmetry of limb use on postnatal days 14, 28, and 42.
RESULTS: There was an 85% survival (45/53) off all the animals, which included deaths during surgery, hypoxia, and after injection of hASC's. Of the 45 survivors, 20 were control animals that underwent carotid
artery isolation and were not exposed to hypoxia. Of the 25 rats that underwent carotid artery ligation and hypoxia, 30% were subjected to normothermia and 70% were exposed to 4 hours of hypothermia. There was
no statistical significance in the distance and time spent on the Rotarod after 6 weeks between HIE animals injected with hASC's and control animals. There was an improvement in the distance run after 6 weeks of
the control animals that received the stem cells (p=0.04). In this preliminary study, there was no significant difference between cylinder test at 2 weeks.
CONCLUSIONS: Rats with HIE treated with hASCs showed similar performance in specific long-term neurodevelopmental aspects when compared to the control group. Further analysis of cognitive and
histochemistry is needed to evaluate the effectiveness of hASC's and HT use in HIE.
Filename: 755641
Presenting Author: Dayanand N. Bagdure, MBBS MPH
Department/Institution/Address: Pediatrics, University of Maryland, 110 S Paca St 8th Floor, Baltimore, Maryland, 21202, United States
Phone: 4103286957
Fax:
Title: The Hospital Impact and Resource Utilization of Pediatric Encephalitis over a 10 year period
Dayanand N. Bagdure1, Jason W. Custer1, Suchitra Rao2, Kevin Messacar2, Samuel Dominguez2, Brandon W. Beam3 and Adnan Bhutta1. 1Pediatrics, University of Maryland, Baltimore, MD; 2Pediatrics, Children's
Hospital Colorado, Aurora, CO and 3Informatics, Arkansas Children's Hospital, Little Rock, AR.
BACKGROUND: Encephalitis is inflammation of the brain, etiologies varying from infectious to immune mediated. Children have the highest incidence of encephalitis. Little data exists about the health care burden due
to encephalitis in United States.
OBJECTIVE: The aim of this study was to report on the hospital impact, diagnostic work-up and treatment of pediatric encephalitis in the United States over a 10 year period.
DESIGN/METHODS: We queried thePediatric Health Information Systems (PHIS), which comprises data from 40 hospitals across the nation. Patients hospitalized with the diagnosis of encephalitis from 2004-2013
were included. Demographic data, laboratory and resource utilization data, disposition and outcome data were analyzed using descriptive analysis.
RESULTS: From 2003-2014, there were 9009 cases of encephalitis, and 22% of admissions were from referring emergency rooms or clinics (n =2035). The number of children with encephalitis have steadily
increased over the years, 689 in 2004 to 1046 in 2013. The average age was 9 years and 50 % (4518) were females. African American comprised of 12.8% (1162) and white children were 34.6% (3119) of the cohort.
1922 (22%) of the patients had seizures during their hospital stay. The percentage of patients hospitalized having seizures each year increased over the decade from 10.5% to 27.8%. Average of length of hospital
stay was 15.2 days. 4707 (52%) children had a spinal tap and cerebrospinal fluid cultures were sent in 3666 (40%) of the cohort. Vancomycin, ceftriaxone and acyclovir were used with the same frequency (30%).
Anti-epileptic use varied, with the most common being levetiracetam (24%), barbiturates (21%) and fosphenytoin (20%).
CONCLUSIONS: Encephalitis causes significant morbidity in children leading to a large burden on pediatric hospitals and significant resource utilization. Seizures in children with encephalitis are being detected with
increasing frequency. There is a wide variation of anti epileptic and antimicrobial use among institutions. Prospective studies are necessary to better understand treatment and intervention strategies for children with
encephalitis and their impact on outcomes.
Filename: 751909
Presenting Author: Panagiotis Kratimenos
Department/Institution/Address: Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, 245 N. 15th Street, New College Building, MS 1029, Philadelphia, PA, 19102, United
States
Phone: 215-762-7515
Fax: 215-762-7960
Title: Effect of Concurrent Administration of LEHD With Hypothermia on Cam Kinase IV Activity after Hypoxia-Ischemia in Newborn Piglet Brain
Panagiotis Kratimenos1, Shadi Malaeb1, Ioannis Koutroulis1, Jane McGowan1 and Maria Delivoria-Papadopoulos1. 1Pediatrics, Drexel University and St.Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: Therapeutic Hypothermia (HT) is shown to ameliorate the neural injury and improve the neurodevelopmental outcome of survivors with hypoxic ischemic (HI) encephalopathy. Investigating
neuroprotective strategies, we have previously shown in newborn piglet brain that hypoxia results in increased activation of caspase-9 mediated by Src kinase and that concurrent administration of the Src kinase
inhibitor PP2 with HT further attenuates HI-induced activation of CaM Kinase IV compared to HT alone. Post-HI inhibition of Src kinase prevents nuclear Ca2+influx thus preventing CaM kinase IV-dependent
CREB-mediated transcription of pro-apoptotic proteins that induce neuronal apoptosis.
OBJECTIVE: The present study tests the hypothesis that concurrent administration of LEHD, a specific Caspase 9 inhibitor, with HT after HI will further decrease activation of CaM Kinase IV activity.
DESIGN/METHODS: Ventilated piglets were exposed to HI [FiO2 0.07 for 1 hr and hypotension (40% decrease in systolic BP from baseline)] then returned to FiO2 0.21 to restore O2 and BP. Piglets received either
saline or a selective caspase 9 inhibitor, LEHD; (1 mg/kg, i.v.) immediately after HI and were cooled to 33°C for 4 hrs. CaM Kinase IV activity in the nuclear fraction of the cerebral cortex was measured by 33P
incorporation into specific substrate.
RESULTS: The data show that concurrent administration of caspase 9 inhibitor LEHD with HT further attenuates HI-induced activation of CaM Kinase IV compared to HT alone. CaM Kinase IV activity (pmol Pi/mg
protein/min; M±SD) was 1699.5±832 in Nx-NT piglets (n=4), 1795±715 in Nx-HT piglets (n=3), 4692±312 in HI-NT piglets (n=4), 4078±870 in HI-HT piglets (n=3; p<0.05 vs Nx-HT) and 2418±436 in HI-HT piglets
treated with LEHD after HI (n=4; p<0.05 vs HI-HT).
CONCLUSIONS: We propose that post-HI inhibition of caspase 9 blocks the activation of caspase 3 which in-turn targets and deactivates the CaM kinase IV-dependent CREB-mediated transcription of pro-apoptotic
proteins that induce neuronal apoptosis. As the occurrence of HI is unpredictable, in the acute phase of injury, the use of neuroprotective agents such as LEHD may provide an adjunct therapy to HT in the post-HI
period. We suggest that concurrent treatment with apoptosic inhibitors augments neuroprotection achieved by HT in newborn piglets.
Filename: 751473
Presenting Author: Peter Osgood
Phone: (215) 762-7515
Fax: (215) 762-7960
Title: Effect of Pre-Hypoxic Src-Kinase Inhibition on Cerebral Hypoxic Injury in Newborn Piglets
Peter Osgood1, Geoffrey Bajwa1, Jherna Balany1, Shadi Malaeb1 and Maria Delivoria-Papadopoulos1. 1Dept. of Pediatrics, Drexel University and St. Christopher's Hospital for Children, Philadelphia, PA.
BACKGROUND: We have previously shown that hypoxic cerebral injury is associated with decreased Na+ K+ ATPase activity and increased free radical injury in the newborn piglet brain. Na+ K+ ATPase activity
serves as an index of neuronal cell membrane integrity. We have also shown that src-kinase is increased and that src-kinase inhibition decreases markers of apoptotic cell death in the brain following hypoxia.
OBJECTIVE: The present study tests the hypothesis that pre-hypoxic administration of a src-kinase inhibitor can restore cellular Na+ K+ ATPase activity in the cerebial cortex of the newborn piglet.
DESIGN/METHODS: Ventilated piglets were either maintained in normoxia (Nx) or exposed to one hour of hypoxic conditions [FiO2 0.07 for 1 h
(Hx). Piglets in the Hx group, were given either normal saline (placebo) or the src-kinase inhibitor PP2 (4-amino-5-(4-chlorophenyl)-7-(dimethylethyl)pyrazolo[3,4-d]pyrimidine)(PP2+Hx) 30 minutes prior to hypoxia.
After this experimental period, the cerebral cortices were homogenized and the membrane fractions were isolated. Protein content was determined using a standard protein assay. Na+ K+ ATPase activity of the
plasma membranes was measured spectrophotometrically by determining the rate of inorganic phosphate liberation from ATP during the reaction (µmol/mg/hr). Enzyme activity in the respective groups was compared
via one-way ANOVA and was expressed as mean ± SD. This data served as an index of neuronal cell membrane integrity.
RESULTS: Normoxic controls showed Na+ K+ ATPase activity of 28.5 ± 3.4 µmol/mg/hr (N=4). Hx samples showed Na+ K+ ATPase activity of 16.0 ± 0.2 µmol/mg/hr (N=2; P<0.05 vs Nx). PP2+Hx samples
demonstrated activity of 29.6 ± 5.7 µmol/mg/hr (N=P). The data show that Na+ K+ ATPase activity was decreased by 43% in Hx samples from the Nx baseline but that PP2+Hx membranes exhibited normal levels of
enzyme activity.
CONCLUSIONS: We conclude that pre-hypoxic administration of the src-kinase inhibitor PP2 results in an increase in Na+ K+ ATPase activity. We propose that this increased Na+ K+ ATPase activity suggests
improved neuronal cell membrane integrity following hypoxic cerebral injury. Src Kinase inhibition may provide an opportunity for neuroprotection following hypoxia.
Filename: 753307
Presenting Author: Santosh Kaipa, MD
Department/Institution/Address: Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, United States
Phone: 410-336-9757
Fax: 718-654-6692
Title: Clonidine: An Established Drug with New Risks for Adverse Drug Events in Pediatric Patients
Santosh Kaipa1, Nilam Gandhi1, Susan Villegas1, Gabriella Azzarone1, Regina Cregin1, Susan McAllen1, Chhavi Katyal1 and H. Michael Ushay1. 1Pediatric Critical Care Medicine, The Children's Hospital at Montefiore,
Bronx, NY.
BACKGROUND: A recently added indication for ADHD and its increasing use in the ICU for treatment of abstinence symptoms related to infusions of dexmedetomidine (dex) have contributed to growth in the number
of pediatric patients receiving oral clonidine. A recent cluster of 3 adverse drug events (ADEs) related to clonidine occurred over a 2 month period and triggered a review of clonidine safety.
OBJECTIVE: To review 3 serious medication events related to clonidine and present interventions enacted to prevent further incidents.
DESIGN/METHODS: Case 1 was a 7 year old with ADHD who received 0.5 mg of clonidine instead of 0.05 mg. The patient required naloxone and was admitted to the PICU for 24 hours. Case 2 was a 13 year old
with CHARGE who received 0.5 mg clonidine twice a day in the hospital instead of 0.05 mg. The error was recognized at discharge medication reconciliation. Asymptomatic at the time, the patient returned sleepy and
bradycardic resulting in a 3 day hospitalization. Case 3 was a 25 day old patient with TGA who was started on clonidine for abstinence after a dex infusion. The dose requested was 2 mcg, but 0.020 mg (20 mcg) was
ordered due to an error in converting mcg to mg. Upon recognizing the occurrence of these errors, an interdisciplinary task force (ITF) was formed to review clonidine safety.
RESULTS: In reviewing the 3 ADEs the ITF found that dosing references for clonidine are confusing with fixed, mg/kg and mcg/kg dosing depending on the indication. Even trained personnel are prone to make errors
when converting mcg to mg and back. Though its use is increasing, pediatric providers are relatively unfamiliar with clonidine. Psychiatrists usually prescribe clonidine for ADHD. Our CPOE system restricts ordering
clonidine to mg thus requiring mcg to mg conversions, a source of potential error. The ITF recommended several interventions to reduce potential clonidine ADEs including notices on CPOE screens indicating how to
convert from mcg to mg, modification of clonidine order screens in CPOE and distributing a nursing practice alert. Requirements were enacted that all clonidine orders are to be in mg, that an indication be noted for all
orders and that the mg/kg or mcg/kg dosage be explicitly stated.
CONCLUSIONS: Oral clonidine use is increasing in pediatrics and thus is the risk of ADEs. Interventions are being implemented to reduce the incidence of ADEs.
Filename: 755439
Presenting Author: Shaon Sengupta, MD, MPH
Department/Institution/Address: Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, United States
Phone: 001-2674279736
Fax:
Is Presenting Author a Trainee? Yes, Other - T32 postdoctoral fellow
Title: Hyperoxia Interacts With Circadian Disruption To Worsen Neonatal Lung Injury Through Modulation of Rev-erba
Shaon Sengupta1, Guang Yang1, Mekdes Yohannes1, Alexa Sadreameli1, Andrew Parsons2 and Phyllis Dennery1,2. 1Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA and 2Pediatrics, University of
Pennsylvania, Philadelphia, PA.
BACKGROUND: Circadian genes regulate Redox homeostasis. In vitro, we have shown that sustained levels of core circadian gene, Rev-erbα (which regulates inflammation and differentiation) protein pre-conditions
cells to withstand oxidative stress induced by H2O2 and hyperoxia. However, the role of Rev-erbα in the developing lung, especially pulmonary vasculature, in response to hyperoxia is not known.
OBJECTIVE: We determine whether circadian disruption induced by constant light exacerbates hyperoxic lung injury. Given its roles in integrating various antioxidant pathways, we test if disruption of Rev-erbα protein
in neonatal mice, exacerbates hyperoxic lung injury.
DESIGN/METHODS: Newborn (<12 hrs old) C57Bl/6 WT were exposed to [1] >95% O<sub style="color: #333333; font-family: 'Times New Roman';">2 + constant light (O<sub style="color: #333333; font-family:
'Times New Roman';">2+CL); >95% O<sub style="color: #333333; font-family: 'Times New Roman';">2 + 12hr light-dark cycles (O<sub style="color: #333333; font-family: 'Times New Roman';">2+LD) cycles; Room
Air + CL (RA+CL) [4] RA + 12h LD cycle (RA+LD) for 3 days and lungs harvested at 6am, 10am, 6pm and 10pm.
Rev-erbα KO, their WT littermates and mice expressing a degradation-resistant-phosphomimetic form of Rev-erbα (SD) and WT littermates were exposed to O2+CL OR RA+LD for 3days as above and lungs
harvested on day 3 or after recovery in RA/12h LD on day14 and 28. The expression of circadian genes (Rev-erbα and Bmal1), downstream targets (p21, Foxo3, IL-6, VEGFa) and vascular makers (angpt1, tie1, flt1,
flk1) were determined. Lung histology (alveolar architecture, fibrosis and vessel density) and proliferative cell nuclear antigen (PCNA)] staining was performed.
RESULTS: In the WT animals, lung Rev-erbα and Bmal1 mRNA levels were significantly decreased in O2+CL and markers of oxidative stress ( HO-1 and peroxiredoxin1) were significantly increased.
Rev-erbα KO mice had significantly increased levels of p21 in O2+CL compared with WT animals, while it was decreased Rev-erbα SD mice and PCNA staining was increased. In Rev-erbα KO mice exposed to
O2+CL, vascular makers was significantly blunted versus WT and endothelial marker (PECAM) was reduced.
CONCLUSIONS: In the neonatal lung, hyperoxia and circadian dysregulation, disrupt Rev-erbα, which leads to decreased cell proliferation and impaired vascularization.
Filename: 754633
Presenting Author: Usama Younis, MD
Department/Institution/Address: The Regional NICU, Maria Fareri Children's Hospital at Westchester Medical Center - NYMC, 100 Woods Road, Valhalla, NY, 10595, United States
Phone: +1 914-493-8558
Fax: +1 914-493-1488
Title: Genetic Variation of NFkBIA Gene Protects from Bronchopulmonary Dysplasia in Extremely Low Birth Weight Infants
Usama Younis1, Lynnette H. Kim1, Alexander Feldman1, Umesh Paudel1 and Lance A. Paron1. 1The Regional NICU, Maria Fareri Children's Hospital at Westchester Medical Center at NYMC, Valhalla.
BACKGROUND:
Table (1) - Demographic Characteristics
No BPD (n = 60)
BPD (n = 99) p value
Birthweight (grams) [Mean ± SD]
812 ± 112
706 ± 139
< 0.001*
Gestational age (weeks) [Mean ± SD]
26 ± 1.7
25 ± 1.6
< 0.001*
Male Gender
24 (40%)
46 (46%)
0.5
Race Caucasian
20 (33%)
27 (27%)
0.4
Black
12 (20%)
31 (31%)
Hispanic
24 (40%)
37 (37%)
Other
4 (7%)
4 (4%)
PDA (medical ± surgical rx)
29 (17%)
71 (70%)
0.005 *
NEC (Bell’s stage ≥ IIA)
2 (1.2%)
11 (11%)
0.1
IVH (≥ Grade 3)
5 (3 %)
15 (15%)
0.3
PVL
2 (1.2%)
15 (15%)
0.04 *
Table (2) - Genotype Distribution (rs2233406)
No BPD (n = 60)
BPD (n = 99) p value
CC
28 (47%)
64 (65%)
Ct
21 (35%)
28 (28%)
tt
11 (18%)
7 (7%)
C
0.64
0.79
t
0.36
0.21
Z test
1.9
0.03*
0.06
Susceptibility of preterm infants to inflammation, oxidant damage, and stretch leading to bronchopulmonary dysplasia (BPD) is modulated at the inflammatory checkpoint of the cell-NFkB, which is usually bound to
inhibitory proteins IkB. There are functional genetic variants of the NFkB transcription factor, which may result in perturbations in this response.
OBJECTIVE: We investigated associations between functional variants of NFkBIA and BPD in ELBW infants.
DESIGN/METHODS: This is an ongoing cohort study that enrolls infants with BW <1 kg, without congenital or chromosomal anomalies. BPD is defined as need for O2 at 36 weeks post-menstrual age. DNA was
isolated from buccal mucosal swabs (N= 159) and subjected to allelic discrimination using Taqman probes during real-time PCR. Chi Square/Fisher Exact analyses, z test, and t-test were performed with statistical
significance at P<0.05.
RESULTS: As expected, birth weights and gestational ages were smaller in the BPD group. Data showed a significant association of the minor allele “t” of NFkBIA SNP rs2233406 with No BPD, while SNPs rs2233409
and rs3138053 did not show significant association. The BPD group had significantly more PDA, but not IVH ≥ grade 3 or NEC ≥ IIA.
CONCLUSIONS: In this pilot study, ELBW infants without BPD were found to have a significant association with the SNP rs2233406 of NFkBIA. We speculate that this specific NFkBIA genetic variant results in a
perturbation of the NFkB-IkB inflammatory checkpoint, upsetting the balance against pro-inflammation, hence protecting ELBW infants from BPD.
Filename: 755018
Presenting Author: Aneela Bidiwala, MD
Department/Institution/Address: Pediatric Pulmonary Department, Winthrop University Hospital, 259 First St, Mineola, NY, 11501, United States
Phone: 5163161727
Fax:
Title: Impact of Residents' Education in ICS Utilization on Acute Asthma Outcome: A Quality Improvement Initiative
Aneela Bidiwala1, Claudia Halaby1, Kathy Mckillop1, Melodi Pirzada1 and Lynn Quintos1. 1Pediatrics Pulmonary, Winthrop University Hospital, Mineola, NY.
BACKGROUND: Asthma is a leading cause of Emergency department visits and re-admissions in pediatrics. In collaboration with the Asthma Coalition of Long Island, we implemented the BREATHE Bringing
Resources for Effective Asthma Treatment through Health Education program. The use of inhaled corticosteroids (ICS) is a first line preventative therapy for persistent asthma. Baseline needs assessment at our
institution showed that only 68 % of patients with persistent asthma were discharged home on ICS.
OBJECTIVE: This initiative focuses on improving the number of asthmatics discharged home with ICS to 75%.Our global aim is to achieve 50% reduction in ED visits and re-hospitalizations due to asthma during a
one year period.
DESIGN/METHODS: Process Measure:Number of prescribed ICS over total number of patients discharged.
Outcome Measure:Percentage of ED utilization and In-patient admissions in our cohort prior to and one year after enrollment in the BREATHE program.
For our first PDSA cycle our key driver was the implementation of a multi-modal teaching plan utilizing NHBLI guidelines to improve pediatric resident's knowledge of asthma severity assessment and the use of
ICS.Our second PDSA cycle was to monitor prescriptions for ICS on discharge, improve documentation of ICS on BREATHE data sheet, and provide direct feedback to house staff. Our 3rd PDSA cycle consist of
giving parents the ICS prescription in advance of projected discharge and asking parents to bring the medication prior to discharge for review
RESULTS: 276 pediatric patients with persistent asthma were hospitalized at Winthrop University Hospital from May 2013 to July 2014.Of this 77 % received prescription for ICS on discharge as compared to 66%
before intervention,which represents 14% improvement.
A one year post intervention cohort of 93 patients had 68 % reduction in emergency department revisits and 88 % reduction in one year hospital readmission rate.
CONCLUSIONS: Multimodal education coupled with active intervention such as data monitoring and direct feedback to staff, lead to increases in prescription of ICS. The addition of direct engagement of the family on
filling the prescription is directed to improve compliance.
The significant reduction in acute care utilization in our cohort supports the importance of a comprehensive education and discharge action plan for patient with persistent asthma.

2015 Eastern SPR Annual Meeting - American Pediatric Society

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