United States

Background
Recurring lab studies in the form of ABG, VBG, CBC, electrolytes, renal function panels and coagulation measurements are commonplace in PCICU. This practice pattern provides an element of safety by providing surveillance of patient’s volatile physiologies. This practice has unintended negative consequences including expense, laboratory “alarm fatigue” for providers, and increased risk of CLABSI. These consequences are intensified when recurring lab studies occur indefinitely and when lab draws are poorly synchronized so that the vascular catheter is accessed more frequently than necessary. 

Methods
The investigators worked with EPIC software professionals to construct a lab order set that speeds order entry, provides a comprehensive, individualized menu of lab tests most commonly ordered in the PCICU, enforces synchronization of blood draws, caps the number of days the selected labs will be drawn, and notifies the care team when slates of recurring lab tests are expiring. We wish to examine the effect of this intervention on the total number of labs drawn per patient per day, the daily cost, the number of times vascular catheters are accessed, and the number of patient resuscitations observed. Our lab order set is currently under construction by EPIC.

Results
We are currently receiving via automated EPIC electronic database a daily report of the number of each type of lab test performed per patient during each 24-hour period for one month. From this data we will tabulate a) the total number of each type of lab test performed per patient per day, b) the estimated total cost and charge for all lab testing per patient per day, and c) the number of times per day that blood is drawn from a vascular catheter per patient per day. 

As surrogates of potential negative consequences of lab reduction, we will monitor number of patient resuscitations that occur during the pre-intervention and post-intervention phases and number of times per patient per day that vascular catheters are accessed. We will compare these outcomes before and after implementation. Finally, to assess compliance, we will express the percentage of the average daily census who have an active laboratory order set in use with a specified expiration date. 

Conclusion
It is our hope that the convenience and simplicity of the PCICU order set will result in a) regular utilization by our providers, b) reduced overall lab testing, c) reduced cost and patient charges, d) fewer accessions of the indwelling vascular catheters, and e) no increase in resuscitation events in our intensive care unit.


AMA Research Challenge 2024 

Design and evaluation of an individualized lab order set in EPIC to decrease recurrent lab draws in the Pediatric Cardiac Intensive Care Unit (PCICU)

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AAPT SM 20

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Does Height of Fever Influence the Probability of Serious Bacterial Infections in Febrile Children? 



Objective 



Fever represents 10% to 25% of pediatric emergency department (ED) visits in young children. Most children presenting to ED with febrile illness are self-limited viral infections. On the other hand, Serious Bacterial Infection (SBI) rates are low. They are estimated to occur between 6% of infants younger than 3 months and 5% to 7% of children between 3 and 36 months of age. Although it is challenging to differentiate between viral and bacterial infections based on the degree of fever, historically, high fever has been associated with increased incidence of SBI. Fever may be the only presenting finding, as symptoms may be subtle, and early infections may not be clinically apparent. Therefore, there is considerable variability in evaluation, treatment, and overall resource utilization in managing febrile children presenting to ED. This study aims to determine whether the height or duration of fever can predict the likelihood of SBI in children. 



Methods 

We performed a retrospective review of febrile children (3-36 months old) who presented to the Pediatric ED between January 2017 and December 2021. Children 3-36 months of age presenting to ED with a documented temperature of 102.2 0F (39 0C) or more were included. Older age groups and/or critically ill children requiring resuscitation were excluded. Clinical characteristics, such as temperature at admission, fever duration, admission diagnosis, and associated symptoms, were analyzed. Serious Bacterial Infection (SBI) was defined as Pneumonia, Urinary Tract Infection (UTI), Meningitis, or Sepsis/Bacteremia. Data was tabulated as number, frequency, median, and range. 

Result 

We reviewed 444 febrile children, including 36 (8%) with SBI and 408 (92%) without SBI. The mean temperature at admission of children with an SBI was significantly higher than those without SBI (mean Temp 103.0°F±1.6 vs. 102.1°F±1.3, p<0.001) and 64% did have an admitting temperature ≥102.20F (p=0.022). There was a significant difference in SBI versus non-SBI group in fever duration (2.5±1.6 vs. 1.6±1.1 days, p<0.001), WBC count (14.2±7.7 vs. 10.4±3.9, p<0.001), Procalcitonin level (2.2±3.1 vs 0.8±1.7, p=0.020) and immunization status (58.3% vs 70.3%, p<0.018). The SBI was 64% pneumonia and 36% UTI. Both groups had associated symptoms (cough, rhinorrhea, vomiting/diarrhea) at presentation to the ED (SBI, 86.1% vs. non-SBI, 85.8%, p=0.95). 

Conclusion 

The rate of SBI was 8% in our patient population, and it was associated with a longer fever duration. Although the mean temperature was slightly higher in the SBI group than in the non-SBI group, it was not strongly associated with an SBI. Thus, a single parameter, such as the degree of fever alone, cannot be used to stratify the risk of febrile children. Height and duration of fever, along with increased WBC count, could indicate the severity of illness and call for further investigation.

Does Height of Fever Influence the Probability of Serious Bacterial Infections in Febrile Children?

Effect of Environmental PFAS Exposure on Pediatric Neuromorphometry: The HOME Study

BACKGROUND
Per- and poly-fluoroalkyl substances (PFAS), also known as “forever chemicals”, is a class of poorly biodegradable chemicals widely used in commercial and industrial applications. The neurodevelopmental effects of PFAS have not been previously studied, warranting investigation of this prevalent and persistent chemical class.

The Health Outcomes and Measures of the Environment (HOME) Study is an ongoing pregnancy and birth cohort study (enrollment from 2003-2006) designed to evaluate known and potentially adverse environmental exposures affecting infant and child health. Thus, we examined the impact of PFAS exposure on pediatric structural MRI (sMRI) imaging acquired in HOME Study participants. 

METHODS
468 pregnant individuals were enrolled in the HOME Study. Offspring serum concentrations (ng/mL) of five PFAS (PFOA, PFOS, PFHxS, PFNA, and PFDEA) were measured at multiple time points. High-resolution T1-weighted MRI was performed at 12 years. Post-processing of data was performed in CAT12 software, allowing for voxel-based and surface-based neuromorphometrical analysis. 215 children had complete serum PFAS, sMRI, and covariate information.

We created a general linear model to test for changes in neuromorphometry associated with exposure to log2-transformed PFAS compounds at various time points, while controlling for gender, race, birth weight, and maternal IQ.

RESULTS
We found multiple significant (p-value < 0.05) associations with a small Cohen’s effect size (0.2 < d < 0.5) between PFAS exposure and neuromorphometry (at 12 years old). PFOA had a significant effect on GM volume at P3 and P4, while PFNA had a significant effect on GM volume at 11-14 years. PFDEA had a significant effect on cortical surface area at 7-9 years. PFNA had the most significant (p = 0.009) and largest effect size (d = 0.44) on both voxel-based and surface-based morphometry at the 11-14 years.

CONCLUSION
PFOA, PFNA, and PFDEA play a significant role in brain-wide neurodevelopment, although there was not sufficient evidence to state that PFOS or PFHxS were influential in our model. There were varied effects depending on the particular exposure time point. Ultimately, this study provides novel evidence regarding the neurodevelopmental impacts of a highly prevalent and persistent chemical class, justifying extensive further investigation into its safety. Limitations of this study included somewhat small sample size and only one imaging time point. 

Future analysis will focus on the relationship between PFAS, imaging, and behavioral outcomes. New imaging data at 18 years is also being gathered.

Effect of Environmental PFAS Exposure on Pediatric Neuromorphometry: The HOME Study

Background: 
Pediatric primary care is an ideal setting to prevent mental and behavioral health disorders given the high frequency of contacts through well-child visits birth to age 5. Bjelland et al have detailed that childhood mental and behavioral health have strong associations with adult well-being1. As such, early detection and intervention is key to addressing the secondary effects of behavioral health issue; however, many barriers, such as family circumstances and lack of awareness of behavioral health programs, hinder successful access to behavioral healthcare resources in pediatric practice2. The goal of this study was to examine the perspectives of families with young children on barriers to accessing behavioral health care and how to improve access. 
Methods:
Semi-structured one-on-one virtual interviews were used to qualitatively explore the perspectives of families with young children regarding access to behavioral healthcare. Participants were recruited from the CHP-Primary Care Center (PCC) in Oakland, a clinic serving a high proportion of Medicaid-eligible families (>85%). Interviews focused on thoughts and experiences related to accessing behavioral healthcare for children, with demographic information collected at the end of each interview. Deductive and inductive methods were used to develop a codebook followed by content and thematic analysis techniques to identify recurring themes and patterns, utilizing the program Nvivo.
Results: 
Participants included 27 caregivers (M age=30.7, SD=6.3) of at least one child under the age of 5. Eleven percent of caregivers identified as Hispanic. Seventy percent identified as African American and 30% as white. Forty-four percent reported an income below 40k and 48% were employed full-time. The analysis of the interviews revealed several interconnected barriers that families face when accessing behavioral healthcare for their young children, categorized into logistical, financial, and psychosocial challenges. Logistical barriers included 1) childcare, 2) time, 3) transportation, and 4) employment-related issues. Financial barriers were evident in the form of 1) inadequate insurance coverage, and 2) broader financial constraints that made affording care difficult. Psychosocial barriers included 1) education and understanding of behavioral health issues and 2) pride and stigma, which deterred some parents from seeking care due to concerns about judgment.
Conclusions: 
These findings underscore the need for a multifaceted approach addressing the diverse challenges families face in accessing behavioral healthcare services for their children. Comprehensive solutions must consider both systemic and individual factors, such as improving insurance coverage and financial support, enhancing public transportation options, and providing flexible appointment scheduling, while also advising initiatives aimed at increasing education about behavioral health and reducing stigma. Addressing these barriers in a coordinated manner could significantly enhance access to behavioral healthcare services for young children.


Exploring Caregiver’s Perspectives on the Barriers to Accessing Behavioral Healthcare for their Children

Selective mutism (SM), categorized under anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), presents challenges in timely identification and treatment, which is especially crucial for pediatricians as early intervention can significantly improve a child’s social and emotional development. SM is characterized by a child’s inability to speak in certain situations but speaks adequately in other settings. While recorded SM diagnoses may not be largely prevalent within the US, affecting approximately 0.2-1.6% of people. SM's significance lies in its potential impact on a child's social, academic, and emotional well-being. This retrospective observational study explores pediatrician referrals to a specialized program for adolescents with SM, aiming to address awareness gaps and improve early intervention. Findings reveal a notable 11.5% contribution from pediatricians, compared to the other referring parties-- searching online (33.7%), other (32.6%), psychologist (8.6%), friend (8.5%), other therapist (4.6%), and recruitment event (0.5%)--emphasizing the need for targeted clinician awareness initiatives. Recognizing the potential benefits of early intervention, this research underscores the importance of collaborative efforts, education, and specialized programs in enhancing referral patterns by pediatricians for improved outcomes in selective mutism, as children are more likely to see their pediatrician before any of the other previously listed referral parties. The study acknowledges limitations in its design and suggests avenues for future research to explore factors influencing clinician awareness and the long-term outcomes of early SM treatment.

Retrospective Analysis of Pediatrician Referral Patterns for Selective Mutism Intervention: Unveiling Silent Echoes in Clinical Practice

Abstract Title: Stool Sphingomyelin Analysis to Predict Parenteral Nutrition-Associated Cholestasis in Very Low Birth Weight Neonates

Authors: Esrig, A., Shenoy, A., Marrs, A., Kolling, G., Moore, S., Papin, J., Sullivan, B. 

Background: Parenteral Nutrition-Associated Cholestasis (PNAC), diagnosed by elevated serum conjugated bilirubin, occurs in preterm infants with very low birthweight (VLBW, <1500g) requiring prolonged parenteral nutrition. Previous untargeted fecal metabolomics from our group identified 12 sphingomyelins as potential PNAC biomarkers. Successful identification of a stool biomarker for PNAC risk could reduce reliance on blood tests and promote preventative interventions to mitigate liver damage.

Methods
We enrolled VLBW infants admitted to a level IV NICU with written consent from a parent. Stool samples were collected biweekly, and clinical data were recorded in a REDCap database. We analyzed stool samples using mass spectrometry for targeted fecal sphingomyelin quantification. Conjugated bilirubin (C. Bili) levels were obtained at the discretion of the clinical team. We identified study participants with PNAC (C. Bili > 1.0 mg/dl) and matched each PNAC case with two controls (enrolled VLBW infants without PNAC) of similar gestational age, birthweight, and sex. We used summary statistics and non-parametric statistical tests to compare clinical variables and sphingomyelin concentrations between cases and controls. The main objective is to validate and quantify fecal sphingomyelins as PNAC biomarkers through targeted metabolomics.
Results

We enrolled 55 VLBW infants, of whom 3 developed PNAC. We matched two controls with these 3 cases and analyzed their biweekly stool samples for sphingomyelin concentrations. Demographics were similar for cases and controls, and cases had more days on TPN Peak sphingomyelin concentrations were higher for cases than controls, but the timing of the peaks relative to PNAC timing varied. Sphingomyelin concentrations were weakly positively correlated with TPN days.


Conclusion
We identified fecal sphingomyelins using targeted mass spectrometry analysis of stool samples from VLBW preterm infants at risk for PNAC. Our preliminary results show variable timing of sphingomyelin elevations relative to PNAC diagnosis and age in controls without PNAC. PNAC is a rare disease requiring large cohorts to determine the utility of fecal sphingomyelin to predict PNAC risk. Successful identification of fecal biomarkers that predict cholestasis before the onset of PNAC could reduce blood testing & liver damage

Stool Sphingomyelin Analysis to Predict Parenteral Nutrition- Associated Cholestasis in Very Low Birth Weight Neonates

Background: Laparoscopic hysterectomy is a common surgical procedure associated with postoperative pain. The Quadratus Lumborum (QL) block has been used as a regional anesthetic during hysterectomy, yet its efficacy remains unexplored. This systematic review and meta-analysis of randomized control trials (RCTs) evaluates the efficacy of QL block in reducing opioid consumption and visual analogue scale (VAS) scores. The aim is to understand its potential benefits in the postoperative period.

Methods: Electronic search was conducted through PubMed, Embase, Scopus, Cochrane, and Web of Science. Relevant articles published from inception until May 20, 2024 were searched. Primary outcome included total opioid consumption within 24 hours and VAS scores within 2, 6, 12, and 24 hours post-operation. Secondary outcomes included time to first opioid demand, time to first ambulation, and adverse events.

Results: Nine RCTs were included. QL block significantly reduced total opioid consumption within the first 24 hours (MD = -10.1mg, 95% CI: -15.2 to -3.6, p = .008). VAS scores were significantly lower within the first 2 hours (MD = -3.6, 95% CI: -4.0 to -0.9, p = 0.046), 6 hours (MD = -2.3, 95% CI: -2.0 to -0.7, p = 0.031), and 12 hours (MD = -1.5, 95% CI: -1.9 to -0.3, p = 0.024). There was no significant difference in time to first opioid demand (MD = 120min, 95% CI: -10 to 50, p = 0.20), time to first ambulation (MD = 120min, 95% CI: -10 to 65, p = 0.15), or adverse events (OR = .78, p = .85).

Conclusion: QL block is an effective analgesia for reducing total opioid consumption and reducing VAS scores in hysterectomy. It does not have a significant impact on time to first opioid demand, time to first ambulation, or adverse events. QL block should be considered for postoperative pain management in hysterectomy.

Efficacy of Quadratus Lumborum Block on Postoperative Analgesia in Hysterectomy: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

Background
Cleft lip and palate (CLP) is the most prevalent congenital malformation in the United States. Approximately 75% of CLP patients will have an alveolar cleft that can impair support of palatal and dental structures. Alveolar bone grafting (ABG) is standard management for alveolar defects, typically with iliac cancellous bone. Previous operative planning has been limited in terms of quantification of alveolar clefts and the amount of graft to obtain sufficient bony bridging across the defect. Here, we examine the potential use of Cone-Beam Computed Tomography (CBCT) and 3-Dimensional (3D) segmentation for volumetric quantification of alveolar clefts.
Methods
A retrospective chart review was performed for patients who underwent ABG since 2018 and CBCT imaging studies for operative planning and outcomes assessment were collected. Peri-operative data, cleft characteristics, demographics, and post-operative data were collected along with CBCT images. ITK-Snap neuroimaging software (University of Pennsylvania, 2023) was used in 3-Dimensional segmentation of CBCT imaging, obtaining measurements of volume and widths of alveolar clefts pre- and post-operatively. Anatomic landmarks were agreed upon by craniofacial orthodontists and surgeons.
Results
68 post-operative studies were identified, with 66 studies demonstrating measurable bony bridging. 11 post-operative studies had enough residual cleft volume to undergo 3D segmentation, 9 of which had measurable bony bridging. 33 pre-operative CBCT studies for patients who underwent ABG were available for 3D segmentation. 21 pre-operative studies were conducted for clefts undergoing primary ABG and 12 were conducted for revisions. 40% of patients who underwent grafting had a bilateral cleft and alveolar defect. For post-operative segmentations of successful ABG, original cleft width averaged 5.35mm, cleft residual volume averaged 559.1mm3, and bony bridging height averaged 6.06mm. Cleft width in patients who required revision was significantly higher compared to those who did not (8.02mm vs. 5.35mm, p=0.011). A comparison between the residual volume of clefts which required revision and those that did not approached, but did not meet, statistical significance (980.2mm3 vs. 559.1 mm3, p=0.058).
Conclusion
3D segmentation has potential in pre-operative planning of alveolar bone grafting. Preliminary results from 3D analysis of CBCT indicate width of cleft may be more influential in ABG success than cleft volume. Comparison of these characteristics of cleft defects may help determine if a threshold exists for increased risk of bone graft failure. Continued analysis will include regression analysis of cleft width and volume corresponding to ABG outcomes, as well as receiver operating characteristic curves to investigate thresholds of failure risk.

3D Volumetric Analysis of Alveolar Clefts Using Cone-Beam Computed Tomography

Background:
Complications following tissue expander (TE) placement for staged oncologic breast reconstruction remain a challenge. Innovations such as dual-port TEs with both filling and drainage ports mitigate seroma risk. Acellular dermal matrix (ADM) has also gained popularity due to superior structural support and cosmesis. ADM is a sterile, bioengineered soft tissue graft used for dermal reinforcement and regeneration. The purpose of this study was to compare outcomes between dual- and single-port TEs with the use of ADM.

Methods:
Retrospective chart review was completed for patients who underwent TE breast reconstruction by a single surgeon between January 2018 and November 2023. Demographics, cancer treatment modality, implant data, and postoperative outcomes were examined. Analysis included descriptive statistics, F-distribution tests, Welch's t-tests, Chi-squared, and Fisher Exact tests.

Results:
154 breasts were included: 118 single-port TEs (74 with ADM, 62.7%) and 36 dual-port TEs (11 with ADM, 31.0%). Premature explant was needed for 15.3% of single-port and 28.5% of dual-port TEs (p=0.328). Explant in both groups was due to infection, wound healing problems, rupture, and seroma. However, premature explant of dual-port TEs occurred predominantly without ADM (p=0.0075), contrasting single-port TEs where ADM use showed no significant difference in explant rate. Further, incidence of infection was higher in dual-port expanders without ADM (p-value=0.0071), whereas single-port TE infection trended higher with ADM use.

Conclusions:
Both single and dual-port tissue expanders are safe and effective for staged breast reconstruction, without significant differences in the rate of premature explantation. In this cohort, ADM appears protective when used with dual-port TEs. It is possible that ADM’s homogenous surface safeguards the drain port from clogging with subcutaneous fat or other tissue, decreasing risk of fluid collection and infection. Routine ADM use with dual-port TEs could reduce complications and improve patient outcomes. Additional research is needed to facilitate evidence-based decision-making on single versus dual-port TE placement and utility of ADM.

Enhanced Performance of Dual-Port Tissue Expanders with Use of Acellular Dermal Matrix

Introduction: 
Heterotopic ossification (HO) is the formation of extra-skeletal bone within soft tissue that occurs after injuries like severe burns. Development of HO complicates healing after injury. We aimed to elucidate factors influencing the development of HO in burn survivors and effects on recovery. 

Methods: 
Using the TriNetX database, a large, federated research network of de-identified patient data, we compared burned patients who developed HO after injury and those who did not. Cohorts were propensity-matched by age, gender, race, ethnicity, and % total body surface area (TBSA) burned. We then evaluated incidences of outcomes after injury among both cohorts.

Results:
Of the population, 0.12% developed HO after injury with most identified greater than 6 months from injury. HO was more common in those with head, upper extremity, or lower extremity burn involvement (p<0.0001). The HO group was older (48.1 vs 19.5 yrs. vs 32.5 vs 22.8 yrs., p<0.001), and male (60.3% vs 51.1%, p<0.001). African American burn patients were more likely to develop HO (22.2% vs 17.5%, p<0.001) than not. Additionally, those with HO exhibited a more than doubled risk of neuropathy, limited joint mobility, and documented edema than those who did not. Additionally, risk of skin breakdown, pain, and depression was higher in those who developed HO while additional reconstructive operations was interestingly lower. 

Discussion: 
Burn survivors more likely to develop HO are older, male, and have greater injury severity. Identification of HO was more likely greater than 6 months from injury. After propensity matching for burn severity and demographic factors, those with HO have comparatively poorer outcomes.

Heterotopic Ossification After Burn Injury Results in Worse Outcomes

Introduction: Plastic surgeons face an elevated risk of involvement in malpractice cases compared to other specialties. Fear of malpractice litigation may influence surgeon behavior and decision-making, potentially contributing to heightened healthcare costs. This study aimed to determine the prevalence and characteristics of malpractice litigation associated with breast implants. 

Methods: A comprehensive search involving the Westlaw Campus Research legal database was conducted to identify all cases involving malpractice complaints and breast implants. All available malpractice cases involving breast implants/prostheses from the earliest available documentation to February 1st, 2024 were retrieved and screened. Cases were included if a patient initiated a medical malpractice or negligence case after undergoing breast augmentation or reconstruction involving implants. Class action suits and cases with limited information were excluded. The extracted data from the cases included the date of the earliest available documentation, initiation location, patient gender, patient vital status, indication for implant(s), involved medical specialties, types of alleged negligence, diagnostic and postoperative complaints, autoimmune-related complaints, involvement of capsular contracture along with subsequent open/closed capsulectomy, and case outcomes. Descriptive statistics were calculated. 

Results: 650 cases were identified after the exclusion of duplicates; 128 cases met the inclusion criteria. Cases were most commonly initiated in the state of Texas (N=17, 13.3%) and New York (N=13, 10.2%) and documentation was dated 1967-2023. All of the cases involved female patients; one woman identified as transgender. Three (2.3%) patients were deceased at the time of the trial. Plastic surgeons were most commonly the defendant(s) (N=113, 88.3%). Malpractice claims were most frequently associated with the initial breast implant placement (N=89, 69.5%), rather than a breast implant removal with or without replacement (N=26, 20.3%). Negligent technique, improper informed consent, and poor postoperative management were cited as reasons for alleged malpractice in 90 (70.3%), 65 (50.8%), and 64 (50.0%) of the cases, respectively. Patients alleged that they did not receive the type of implant (saline vs. silicone) or size of implant they requested in 7 (5.5%) and 5 (3.9%) of the cases, respectively. 20 (15.6%) of the cases were ruled in favor of the plaintiff prior to appeal; 5 cases involved implant-based reconstruction, while 15 cases involved cosmetic implant-based augmentation. Eight patients claimed that their implants led to the development of cancer, autoimmune conditions, or other health conditions; only one case led to a ruling in favor of the plaintiff in 2001. 

Conclusion: 
These findings underscore the importance of comprehensive preoperative education, specifically addressing implant types, demystifying information about breast implant-associated illness, and setting realistic goals surrounding implant sizing. Surgeons should maintain heightened vigilance when patients present with abnormal postoperative changes in the breast tissue. Thorough work-up and placement of appropriate referrals should be conducted to prevent delays in potential breast cancer diagnoses. 


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Does Height of Fever Influence the Probability of Serious Bacterial Infections in Febrile Children?

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