Pediatrics Projects 2020

Project Title: Longitudinal Musculoskeletal Assessment in Juvenile Idiopathic Arthritis

Faculty Mentor: Leandra Woolnough 
Email: l.woolnough@ufl.edu 

Student: Dinia Salmeron 
Email: dsalmeron2@ufl.edu 

Research Project Description:

Juvenile idiopathic arthritis (JIA) refers to a group of autoimmune disorders involving joint inflammation (1). It is a chronic and potentially debilitating condition that is clinically diagnosed in patients less than 16 years old with chronic joint swelling for 6 or more weeks (2). In practice, a clinically active joint is defined by swelling, limitation, pain on motion on musculoskeletal (MSK) exam (3). Recent studies have shown that imaging techniques, including ultrasound (US), may be more sensitive in detecting inflammatory changes in patients with JIA compared to clinical evaluation (4). In particular, ultrasound can reveal subclinical inflammatory changes such as synovial thickening, joint effusion, and hyperemia. Ultrasonographic evidence of inflammation in a clinically inactive joint or set of joints may predict the progression of the disease across time, support reclassification of the JIA subtype, and drive more aggressive therapy (5).US offers unique benefits as it is non-invasive, quick, relatively low-cost, and can be used to examine multiple joints in one sitting. However, the utility of MSK US in diagnosing and monitoring patients with JIA is not well established. We intend to longitudinally follow JIA patients with US from diagnosis, through treatment, and into clinical remission to learn more about the utility of MSK US in this population.

We believe that MSK US will provide a reliable and reproducible assessment of joint inflammation in patients with JIA. MSK US should reveal inflammatory changes that may not be detected during the clinical evaluation. As we learn more about the prevalence and clinical significance of these findings, we can incorporate US as a valuable screening tool in the JIA population. In addition, we believe that physical activity may lead to joint changes in healthy and JIA patients depending on the severity and duration of the activity, with moderate to vigorous activity causing more significant changes. But it may play a bigger role in patients with JIA as they have increased inflammation.

There are multiple aims of the larger study. First, we want to determine the prevalence of ultrasonographic inflammatory changes in patients with JIA compared to healthy controls. We also aim to assess the concordance between clinical assessment and ultrasound regarding active joint counts and signs of inflammation. In addition, we will determine if there are any baseline ultrasonographic changes in clinically inactive joints that predict future clinical signs of active arthritis and if there is a persistence of ultrasonographic changes in JIA patients in clinical remission. For this project, we will collect and analyze data to determine if there is a correlation between physical activity and ultrasonographic joint changes in patients with JIA and healthy controls. We will also conduct a literature review on this topic to evaluate the utility of MSK US in clinical practice and report on any findings regarding the impact of physical activity on joint changes.

References:

1. Ellis JA, Munro JE, Ponsonby A. Possible environmental determinants of juvenile idiopathic arthritis. Rheumatology 2010; 49(3):411–425.
2. Petty RE, Southwood TR, Manners P, et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. The Journal of rheumatology 2004;31:390-392.
3. Ravelli A, Viola S, Ruperto N, Corsi B, Ballardini G, Martini A. Correlation between conventional disease activity measures in juvenile chronic arthritis. Annals of the rheumatic diseases 1997;56:197-200.
4. De Lucia O, Ravagnani V, Pregnolato F, et al. Baseline ultrasound examination as possible predictor of relapse in patients affected by juvenile idiopathic arthritis (JIA). Ann Rheum Dis 2018; 0:1-6.
5. Wakefield RJ, Green MJ, Marzo-Ortega H, et al. Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Annals of the rheumatic diseases 2004;63:382-5.

Project Title: The use of a continuous glucose monitor (CGM) and timing of diabetes-related care in the emergency department (ED) in patients with type 1 diabetes (T1D)

Faculty Mentor: Laura Jacobsen
Email: lauraj@peds.ufl.edu 

Student: Rachel Baker 
Email: rachel.baker@ufl.edu

Research Project Description:

The use of CGM in patients with T1D improves blood glucose control as measured by improved HbA1c. Regular use of CGM also reduces healthcare utilization, specifically emergency room visits, and decreases the frequency of diabetic ketoacidosis and severe hypoglycemic events. There is a lack of studies examining how the use of CGM affects care once in the ED. Patients with T1D presenting to the ED require immediate and often frequent glucose monitoring. For example, if a patient presents to the ED with DKA, their blood glucose should be checked at least every hour while undergoing treatment. Once a CGM is confirmed to be working correctly, it should be used as an asset in the ED in order to identify when hypoglycemia is imminent, when additional therapy for hyperglycemia is needed, as well as decrease the need for frequent laboratory blood glucose and self-monitoring of blood glucose determination. This could decrease ED healthcare costs while improving patient care and satisfaction.

Patient use of CGM may decrease the time to diabetes-specific ED interventions (including insulin administration and other laboratory studies). In the future, this may decrease the need for self-monitoring of blood glucose, lower costs, and decrease the need for nursing staff to perform frequent blood glucose checks in the ED. The increasing uptake of this valuable diabetes technology among patients with T1D has led to improved clinical outcomes. The use of CGM data in the ED setting may add valuable information to aid in the care of patients with diabetes.

The purpose of this study is to determine if there is a significant difference in timing of diabetes-related emergency department (ED) interventions between patients with T1D who use CGM versus self-monitoring of blood glucose only. These results may inform future management of patients with T1D in the ED setting. This study may lead to an increased use of CGM data by ED providers and has the potential to lower costs.

References:

1. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. “Effectiveness of continuous glucose monitoring in a clinical care environment: evidence from the Juvenile Diabetes Research Foundation continuous glucose monitoring (JDRF-CGM) trial.” Diabetes care vol. 33,1 (2010): 17-22. doi:10.2337/dc09-1502
2. Parkin, Christopher G et al. “Continuous Glucose Monitoring Use in Type 1 Diabetes: Longitudinal Analysis Demonstrates Meaningful Improvements in HbA1c and Reductions in Health Care Utilization.” Journal of diabetes science and technology vol. 11,3 (2017): 522-528. doi:10.1177/1932296817693253
3. Chamberlain, James J et al. “Impact of Frequent and Persistent Use of Continuous Glucose Monitoring (CGM) on Hypoglycemia Fear, Frequency of Emergency Medical Treatment, and SMBG Frequency After One Year.” Journal of diabetes science and technology vol. 10,2 383-8. 9 Sep. 2015, doi:10.1177/1932296815604633
4. Lavoie, Megan Elizabeth. “Management of a Patient With Diabetic Ketoacidosis in the Emergency Department.” Pediatric Emergency Care, vol. 31, no. 5, May 2015, pp. 376–380., doi:10.1097/pec.0000000000000429.
5. M Tauschmann et. al. “Reduction in Diabetic Ketoacidosis and Severe Hypoglycemia in Pediatric Type 1 Diabetes During the First Year of Continuous Glucose Monitoring: A Multicenter Analysis of 3,553 Subjects From the DPV Registry.” Diabetes Care, vol. 43, no. 3, January 2020, pp. 40-42., DOI: 10.2337/dc19-1358

Project Title: Variations of Influenza vaccine receipt in pediatric patients with NBS diagnoses and other genetic healthcare needs

Faculty Mentor: Lindsay Thompson
Email: lathom@ufl.edu  

Student: Alexis Hanlon
Email: ahanlon@ufl.edu   

Research Project Description:

Influenza epidemics are a significant cause of mortality and morbidity, with particularly high morbidity among children1. The spread of influenza and associated illness can be prevented with use of the seasonal influenza vaccine2, but during the 2016-2017 flu season only 59% of children were vaccinated3. Recent literature regarding pediatric receipt of the seasonal Influenza vaccine has focused on examining vaccine receipt in children with respiratory diseases, as well as neurological diseases4,1. To our knowledge, however, there remains particularly little research regarding seasonal flu vaccine receipt in children with inborn errors of metabolism5, and no research has focused on examining the rates of seasonal Influenza vaccination within our specific population of genetically vulnerable children. In this study, we will examine the variation in seasonal flu vaccine receipt in the flu seasons from 8/1/2015 to 4/30/2019, within the pediatric population which has received a diagnosis for Down Syndrome, DiGeorge Syndrome, Cerebral Palsy, Muscular Dystrophy, Cystic Fibrosis, Fragile X, or certain Newborn Screening-associated diagnoses. Of note, all members of the population we are examining will be able to receive the seasonal flu vaccine6–8; though certain vaccines should be given with more caution to certain genetically vulnerable children6, the trivalent influenza vaccine is safe for this population6,7. Because increased receipt of the annual flu vaccine decreases mortality and morbidity associated with the influenza virus2, it’s integral to determine if there is a vulnerable population that is in need of further attention regarding vaccination efforts.

Children with the aforementioned diagnoses have a tendency to fall within two groups; one, where children have clinical visits as needed to manage their specific illness, and another where clinical visits aren’t used regularly and ED visits tend to be used to manage exacerbations. In the first group, flu vaccines are more often administered regularly during these clinical visits, in comparison to the second group where flu vaccines tend to be administered less often. We hypothesize that because of the negative cultural views of the flu vaccine, the overall group of vulnerable children will have less receipt of the flu vaccine compared to the normal, healthy pediatric population.

References:

1. Fraaij, P. L. A. & Heikkinen, T. Seasonal influenza: The burden of disease in children. Vaccine vol. 29 7524–7528 (2011).
2. Grohskopf, L. A. et al. Prevention and Control of Seasonal Influenza with Vaccines. MMWR Recomm. Rep. 65, 1–54 (2016).
3. Flu Vaccination Coverage, United States, 2016-17 Influenza Season | FluVaxView | Seasonal Influenza (Flu) | CDC. https://www.cdc.gov/flu/fluvaxview/coverage-1617estimates.htm (2020).
4. Shang, M., Blanton, L., Brammer, L., Olsen, S. J. & Fry, A. M. Influenza-Associated Pediatric Deaths in the United States, 2010–2016. Pediatrics vol. 141 e20172918 (2018).
5. Cerutti, M. et al. Vaccination coverage of patients with inborn errors of metabolism and the attitudes of their parents towards vaccines. Vaccine 33, 6520–6524 (2015).
6. Vaccination in children with inborn errors of metabolism. Vaccine 30, 7161–7164 (2012).
7. Esposito, S. et al. Preliminary data on immunogenicity, safety and tolerability of trivalent inactivated influenza vaccine in children with inborn errors of metabolism at risk of decompensation. Vaccine 31, 5149–5151 (2013).
8. Flannery, B. et al. Influenza Vaccine Effectiveness Against Pediatric Deaths: 2010-2014. Pediatrics 139, (2017).

Project Title: Predicting the development of necrotizing enterocolitis totalis in premature infants

Faculty Mentor: Saleem Islam 
Email: saleem.islam@surgery.ufl.edu

Student: Alya Barq 
Email: abarq30@ufl.edu 

Research Project Description:

Necrotizing enterocolitis (NEC) is a common gastrointestinal emergency in neonates that is characterized by ischemic necrosis of the bowel associated with substantial intestinal inflammation. It is a leading cause of mortality among neonates, primarily affecting preterm infants (1). Necrotizing enterocolitis totalis (NEC-T) is an aggressive variant of NEC that is almost universally fatal (2). This variant is characterized by necrosis of a majority of the intestines, and occurs in approximately 10% of patients diagnosed with NEC (3). A number of studies have been performed to uncover risk factors for the development of NEC. Major risk factors identified by these studies include prematurity and microbial dysbiosis (4,5). Potential protective factors identified include the use of breast milk as opposed to formula (6). NEC-T, however, remains largely unstudied. Despite its extremely poor prognosis, its etiology remains largely unknown. A few studies have aimed to identify predictive factors and have associated a few laboratory findings and clinical features with a greater risk of developing NEC-totalis (7,2) ,but more studies are needed to confirm the reliability of these factors. Given its rapid progression and almost 100% mortality rate, it is imperative to be able to identify these patients as early as possible. Unfortunately, there are currently no clinical parameters that can be used to reliably identify patients who will develop this subset of NEC. The focus of this study is to elucidate predictive factors that can help identify patients at risk for developing NEC-totalis.

Rationale: Early identification of NEC-T development in preterm infants is critically important to mitigate the devastating effects of the disease. Since there are currently no clinical and/or biochemical parameters that can be used to reliably predict NEC-T, this study aims to focus on identifying potential predictive factors for the disease in patients diagnosed with NEC. Hypothesis: We hypothesize that this retrospective study will allow for the identification of parameters that distinguish patients who develop NEC from patients who go on to develop NEC-totalis.

References:

1. Neu, Josef, and W Allan Walker. “Necrotizing enterocolitis.” The New England journal of medicine vol. 364,3 (2011): 255-64.
2. Thompson, A., et al. “Risk factors for necrotizing enterocolitis totalis: a case–control study.” Journal of Perinatology 31.11 (2011): 730-738.
3. Voss, M., et al. “Fulminanting necrotising enterocolitis: outcome and prognostic factors.” Pediatric surgery international 13.8 (1998): 576-580.
4. Hunter, Catherine J., et al. “Understanding the susceptibility of the premature infant to necrotizing enterocolitis (NEC).” Pediatric research 63.2 (2008): 117-123.
5. Carter, Brigit M., and Diane Holditch-Davis. “Risk factors for NEC in preterm infants: how race, gender and health status contribute.” Advances in neonatal care: official journal of the National Association of Neonatal Nurses 8.5 (2008): 285.
6. Sullivan, Sandra, et al. “An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products.” The Journal of pediatrics 156.4 (2010): 562-567.
7. Sho, Shonan, et al. “A novel scoring system to predict the development of necrotizing enterocolitis totalis in premature infants.” Journal of pediatric surgery 49.7 (2014): 1053-1056.

Project Title: Outcomes in open versus laparoscopic inguinal hernia repair in infants at UF Health

Faculty Mentor: Saleem Islam 
Email: saleem.islam@surgery.ufl.edu 

Student: Melanie Justice 
Email: melanie.justice@ufl.edu 

Research Project Description:

Inguinal hernia (IH) is one of the most common surgical conditions in neonates and children.1 Although the definitive management for this diagnosis is surgical repair, the approach utilized is an area of recent debate. Open herniotomy (OH) has been considered the conventional method for over fifty years due to a successful history of low mortality and recurrence rates, while laparoscopic herniotomy (LH) is considered an alternative approach.2-4 Recently though, many institutions, including UF Health, have favored the laparoscopic method due to its minimally invasive nature, improved visual field, potentially lower complications, better cosmetic results, and ability to discover contralateral hernias.3,5,6

With an apparent shift toward the laparoscopic approach in the practice of IH repair, many recent studies have aimed to compare LH to OH in different populations. With regard to recurrence rates, a major outcome measure for IH, most research supports no statistical difference between LH and OH approaches. Some studies have even found fewer postoperative complications associated with the laparoscopic approach, such as fewer respiratory complications, gonadal injury to males, surgical-site infection, and development of metachronous hernia.3,4,7 However, Fujiogi et al. describes one of the major issues with the research comparing LH and OH, which is that many studies conflict in their results regarding postoperative complications, operative time, and postoperative pain, leading to an unclear assessment of whether LH or OH is more successful.4 In addition, there exists no definitive list of which surgical complications are associated with LH compared to OH, and these outcomes have never been measured within the UF Health systems.

By conducting a retrospective chart review of pediatric patients in the UF Health system, we expect that laparoscopic herniotomy (LH) will prove superior to open herniotomy (OH) as a surgical approach to inguinal hernia repair. We hypothesize that laparoscopic herniotomy procedures will have shorter operative and post-operative recovery times and fewer intra-operative and post-operative complications compared to open herniotomy procedures, though we expect no difference in the likelihood of recurrence between the two approaches. It is our goal that our results will provide us with a clear idea of which approach is more successful, and in which patients, so that we can use this to guide future procedures. This information will also help us better counsel patients and their families, by providing supporting evidence and data collected from UF Health itself.

References:

1. Ramsook, Chris. “Inguinal Hernia in Children – UpToDate,” February 21, 2020.
2. Potts, W. J., W. L. Riker, and J. E. Lewis. “The Treatment of Inguinal Hernia in Infants and Children.” Annals of Surgery 132, no. 3 (September 1950): 566–76.
3. Feng, Shaoguang, Lingling Zhao, Zhenqi Liao, and Xiaoming Chen. “Open Versus Laparoscopic Inguinal Herniotomy in Children: A Systematic Review and Meta-Analysis Focusing on Postoperative Complications.” Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 25, no. 4 (August 2015): 275–80.
4. Fujiogi, Michimasa, Nobuaki Michihata, Hiroki Matsui, Kiyohide Fushimi, Hideo Yasunaga, and Jun Fujishiro. “Outcomes Following Laparoscopic versus Open Surgery for Pediatric Inguinal Hernia Repair: Analysis Using a National Inpatient Database in Japan.” Journal of Pediatric Surgery 54, no. 3 (March 2019): 577–81.
5. Esposito, Ciro, Maria Escolino, Francesco Turrà, Agnese Roberti, Mariapina Cerulo, Alessandra Farina, Simona Caiazzo, Giuseppe Cortese, Giuseppe Servillo, and Alessandro Settimi. “Current Concepts in the Management of Inguinal Hernia and Hydrocele in Pediatric Patients in Laparoscopic Era.” Seminars in Pediatric Surgery 25, no. 4 (August 2016): 232–40.
6. Linnaus, Maria E., and Daniel J. Ostlie. “Complications in Common General Pediatric Surgery Procedures.” Seminars in Pediatric Surgery, Complications in Pediatric Surgery, 25, no. 6 (December 1, 2016): 404–11.
7. Saranga Bharathi, Ramanathan, Manu Arora, and Vasudevan Baskaran. “Pediatric Inguinal Hernia: Laparoscopic Versus Open Surgery.” JSLS : Journal of the Society of Laparoendoscopic Surgeons 12, no. 3 (2008): 277–81.

Project Title: Evaluating Use of Script Concordance Data in Pediatric Clerkships

Faculty Mentor: Maria Kelly 
Email: kellymn@peds.ufl.edu 

Student: Pranshu Bhardwaj 
Email: pbhardwaj@ufl.edu 

Research Project Description:

In the health professions, medical knowledge is predominantly tested via summative multiple-choice question (MCQ’s) exams which rely on a testee’s ability to recall information. (1) However, in clinical settings, a patient’s presentation and subsequent diagnosis tends to be more ambiguous than the vignettes presented to students on MCQ’s. (2) The 2014 survey of 1793 residency directors conducted by the National Residency Match Program (NRMP) found that 94% of directors stated that the National Board of Medical Examiners (NBME) United States Medical Licensing Examination (USMLE) Step 1 scores were the most common factor considered when choosing applicants to interview. The same survey found that 80% of directors stated that the USMLE Step 2 Clinical Knowledge (CK) scores were also heavily considered while selecting applicants to interview.3 Beginning in 2022, the USMLE Step 1 exam will transition to pass/fail, necessitating an adjustment in residency’s evaluation of applicants. It is likely that the role of USCMLE Step 2 CK/CS examinations in residency applications may grow. Previous studies have shown a correlation between Script Concordance Tests (SCT) performance and NBME subject exam scores and clinical performance.(4) Of note, NBME subject exams are MCQ examinations administered at the end of each core clinical clerkship at the University of Florida and are used to evaluate students’ final grades in the clerkship. Others found risk factors including low NBME scores, low scores on third-year Objective Structured Clinical Examinations (OSCE) exams, and low faculty ratings on clinical rotations predicted students who would fail Step 2 CS. (5)The study hopes to use SCT exams to construct models in an attempt to identify students at high risk of failing NBME exams, rotations, Step 2 CK, and USMLE Step 2 Clinical Skills examination (Step 2 CS). This method may allow for faster identification of these students, allowing for more effective academic interventions.

Primary Hypothesis:
Script concordance test (SCTs) performance administered during the required third-year pediatric clerkship predicts student performance on existing measures of academic performance including pediatric shelf exam performance, third-year clerkship grades, USMLE Step 1 score, USMLE Step 2 CS/CK scores, and medical decision-making competency scores.

Secondary Hypotheses:
Statistically significant differences exist in performance variability and score on script concordance tests between pediatric faculty and 3rd-year Medical Students.Script concordance tests can differentiate between learners with differing levels of knowledge.

Rationale:
There is a gap in current literature regarding SCTs predictive abilities. This study hopes to use SCT exams to identify students at risk of failing NBME exams, clerkship rotations, and Step 2 CK/CS. This method may allow for faster identification of these students, allowing for more effective academic interventions.

The primary aim of the study is to determine whether SCTs are related to academic outcomes currently associated with medical student education. These include nationally administered exams containing MCQs and standardized patient encounters that are used to assess both pre-clinical and clinical knowledge. The second set of outcomes includes overall letter grades for the medical student’s clerkship as well as specific competency-based performance scores related to the medical decision-making, of problem-solving, competency. It is anticipated that SCTs will serve as sensitive and specific identifiers of students who may experience academic challenges.

The secondary aims including assessing whether there are differences in SCT variability and scoring between students and pediatric faculty and evaluate whether SCTs can differentiate between learners with differing levels of knowledge.

References:

1. Vanderbilt, A., Feldman, M., & Wood, I. (2013). Assessment in undergraduate medical education: a review of course exams. Medical Education Online, 18(1), 20438. doi: 10.3402/meo.v18i0.20438
2. Humbert, A. J., & Miech, E. J. (2014). Measuring Gains in the Clinical Reasoning of Medical Students. Academic Medicine, 89(7), 1046–1050. doi: 10.1097/acm.0000000000000267
3. Gauer, J. L., & Jackson, J. B. (2017, August 1). The association of USMLE Step 1 and Step 2 CK scores with residency match specialty and location. Retrieved April 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5653932/
4. Kelly, W., Durning, S., & Denton, G. (2012). Comparing a Script Concordance Examination to a Multiple-Choice Examination on a Core Internal Medicine Clerkship. Teaching and Learning in Medicine, 24(3), 187–193. doi: 10.1080/10401334.2012.692239
5. Rosenthal, S., Russo, S., Berg, K., Majdan, J., Wilson, J., Grinberg, C., & Veloski, J. (2019). Identifying Students at Risk of Failing the USMLE Step 2 Clinical Skills Examination. Retrieved April 12, 2020, from https://journals.stfm.org/familymedicine/2019/june/veloski-2018-0397/

Project Title: Comparison of transcutaneous hemoglobin measurements in children to the standard capillary hemoglobin measurement in the pediatric outpatient setting.

Faculty Mentor: Maria Kelly 
Email: kellymn@peds.ufl.edu 

Student: Shae Margulies 
Email: smargulies@ufl.edu 

Research Project Description:

Anemia is the condition of having a reduction in red blood cell mass or blood hemoglobin concentration. In a clinical setting, anemia can either be defined as a reduction in hematocrit (the percent of RBCs in a whole blood sample) or a reduction in hemoglobin (the concentration of hemoglobin in whole blood). In toddlers, children, and teenagers, the most common cause of anemia is iron deficiency anemia (IDA).
The risk of IDA is highest in late infancy with a prevalence of 18% at 12 months of age(1), thus the American Academy of Pediatrics recommends universal screening at that age. Iron deficiency anemia is known to cause growth and developmental issues in children, which is why it is crucial to identify and treat IDA as early as possible as the condition is reversible with proper treatment(2,3). Children at risk for anemia would benefit from rapid, noninvasive, office-based testing. The standard screening method is via invasive capillary blood samples or by a complete blood count (CBC) obtained via venous blood sample, which can cause discomfort and distress to both child and parent. Testing via Pronto Pulse Co-Oximeter is low stress, noninvasive, quick, and would likely provide a more desirable option for parents and patients. There have been minimal studies showing the effectiveness of the transcutaneous hemoglobin testing method in pediatric outpatient settings and for screening. Most of the studies published to date have either been performed outside of the U.S., in emergency settings, or have compared the test to the current capillary measurement (4,5,6). These studies have varying results possibly due to the use of data from critically ill patients (6). One study showed an overall good correlation to a laboratory measurement of hemoglobin, although claimed the reliability was limited in cases of poor peripheral perfusion (5).The Pronto Pulse Co-Oximeter works through a similar mechanism as an oxygen saturation machine. It is a portable and durable handheld device, that can measure the SpO2 (amount of oxyhemoglobin as a percentage of hemoglobin available in the blood), pulse, Pi (ratio of pulsatile blood flow to non-pulsatile blood flow) and SpHb (total hemoglobin present in arterial blood). This method is noninvasive as to not cause the patient discomfort and provides results instantly.

The Pronto Pulse Co-Oximeter will show correlation with capillary hemoglobin measurements while causing less discomfort with the screening process. Based on previous studies, it is possible that there will be limitations to the effectiveness of the testing method based on a few variables including patient movement, size and perfusion variations. The Co-Oximeter requires patients to be completely still for at least one minute, which may cause an issue in younger patients and therefore skew the data. The finger size also has to be a certain size and the probe may be too small for younger children. Additionally, patients with co-morbid conditions may have reduced circulation that could cause the test to not be as effective.

The aim of this project is to compare the current method of capillary hemoglobin testing to the new Pronto Pulse Co-Oximeter, and to determine if this new method is a reliable screening tool for IDA in an outpatient pediatric setting. We will compare measurements and assess if there are any differences in regard to visit type (well versus sick visit), age, gender, the presence of underlying medical comorbidities, weight, BMI, and insurance type. These variables were selected to determine if the new transcutaneous method is more reliable in certain patient populations. Additionally, we will perform a cost comparison to see if this new method is more economical than traditional invasive testing.

References:

1. Eun Young Joo, Keun Young Kim, Dong Hyun Kim,Ji-Eun Lee, Soon Ki Kim. Iron Deficiency anemia in infants and toddlers. Blood Res. 2016 Dec;51(4): 268-273.
2. Hsu DP, French AJ, Madson SL, Palmer JM, Gidvani-Diaz V. Evaluation of a Noninvasive Hemoglobin Measurement Device to Screen for Anemia in Infancy. Matern Child Health J. 2016 Apr;20(4):827-32.
3. Bhat A, Upadhyay A, Jaiswal V, Chawla D, Singh D, Kumar M, Yadav CP. Validy of non-invasive point-of-care hemoglobin estimation in healthy and sick children-a method comparison study. Eur J Pediatr. 2016 Feb;175(2):171-9.
4. Bogoch, I. I., Coulibaly, J. T., Rajchgot, J., Andrews, J. R., Kovac, J., Utzinger, J., Panic, G., & Keiser, J. (2017). Poor Validity of Noninvasive Hemoglobin Measurements by Pulse Oximetry Compared with Conventional Absorptiometry in Children in Côte d’Ivoire. The American journal of tropical medicine and hygiene, 96(1), 217–220. https://doi.org/10.4269/ajtmh.16-0505
5. García-Soler, P., Alonso, J. C., González-Gómez, J., & Milano-Manso, G. (2017). Noninvasive hemoglobin monitoring in critically ill pediatric patients at risk of bleeding. Medicina Intensiva (English Edition), 41(4), 209–215. doi: 10.1016/j.medine.2016.06.005
6. Ryan, M. L., Maxwell, A. C., Manning, L., Jacobs, J. D., Bachier-Rodriguez, M., Feliz, A., & Williams, R. F. (2016). Noninvasive hemoglobin measurement in pediatric trauma patients. Journal of Trauma and Acute Care Surgery, 81(6), 1162–1166. doi: 10.1097/ta.0000000000001160

Project Title: Language in Research Recruitment

Faculty Mentor:Lindsay Thompson
Email: lathom@ufl.edu 

Student: Sierra Blashock 
Email: sierrablashock@ufl.edu  

Research Project Description:

In 1993, the National Institute of Health (NIH) passed the Revitalization Act of 1993 which established guidelines for the inclusion of women and members of ethnic minorities as participants in all NIH funded clinical research3. As the NIH is one of the biggest funders of clinical research, this policy has had a significant impact on how researchers have designed and conducted clinical research and clinical trials for almost 30 years. Indeed, the precedent established by this act is a unique development in the United States and has created an environment of inclusivity that is significantly absent among researchers of other countries6.

Nonetheless, the push for inclusion of members of minority populations has revealed several significant barriers to successful recruitment and retention. These barriers include but are not limited to the following: lack of English proficiency, lack of translated materials in potential participants’ native language, mistrust of medical research, social stigma against the associated diagnoses in their local communities, low literacy levels, and concerns about immigration status4,5. How to properly address and overcome these barriers has become an important consideration in the recruitment process5.

Perhaps one of the most seemingly straightforward solutions to two of these barriers is to translate study materials into the other languages of the targeted minority populations and hire recruiters who are proficient in multiple languages. Unfortunately, as researchers have adapted this technique, they have encountered more related barriers; direct translation of study materials is not as simple as previously imagined due to negative connotations surrounding certain words, dialect/regional variations of languages, and the importance of nonverbal communication 5. Nonetheless, the provision of research materials in a potential participant’s native language is an important first step to improving the recruitment of minority populations into clinical research.

A common ineligibility requirement for clinical study participation in a wide variety of fields is lack of English language skills 2. Due to this, the diversity of the potential participant pool is more limited in these studies as many patients do not speak English than in studies that do not have this ineligibility criteria. Therefore, cancer studies that offer multilingual recruitment and study materials will have a more ethnically diverse participant pool as patients who do not speak English will be eligible.

The aim of this project is to determine if the availability of multilingual materials or study staff has a significant impact on increasing the ethnic diversity of the subjects recruited into cancer clinical trials at the University of Florida.

References:

1. Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2016, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2016/, based on November 2018 SEER data submission, posted to the SEER web site, April 2019.
2. Huang, H. Y., Ezenwa, M. O., Wilkie, D. J., & Judge, M. K. (2013). ResearchTracking: Monitoring gender and ethnic minority recruitment and retention in cancer symptom studies. Cancer nursing, 36(3), E1–E6. https://doi.org/10.1097/NCC.0b013e31826909a8
3. Inclusion of Women and Minorities as Participants in Research Involving Human Subjects. (n.d.). Retrieved from https://grants.nih.gov/policy/inclusion/women-and-minorities.htm
4. Laura K. Rooney, Raj Bhopal, Laila Halani, Mark L. Levy, Martyn R. Partridge, Gopal Netuveli, Josip Car, Chris Griffiths, John Atkinson, Grace Lindsay, Aziz Sheikh, Promoting recruitment of minority ethnic groups into research: qualitative study exploring the views of South Asian people with asthma, Journal of Public Health, Volume 33, Issue 4, December 2011, Pages 604–615, https://doi.org/10.1093/pubmed/fdq100
5. Occa, A., Morgan, S.E. & Potter, J.E. Underrepresentation of Hispanics and Other Minorities in Clinical Trials: Recruiters’ Perspectives. J. Racial and Ethnic Health Disparities 5, 322–332 (2018). https://doi.org/10.1007/s40615-017-0373-x
6. Sheikh, A., Halani, L., Bhopal, R., Netuveli, G., Partridge, M. R., Car, J., Griffiths, C., & Levy, M. (2009). Facilitating the recruitment of minority ethnic people into research: qualitative case study of South Asians and asthma. PLoS medicine, 6(10), e1000148. https://doi.org/10.1371/journal.pmed.1000148
7. Symonds, R. P., Lord, K., Mitchell, A. J., & Raghavan, D. (2012). Recruitment of ethnic minorities into cancer clinical trials: experience from the front lines. British journal of cancer, 107(7), 1017–1021. https://doi.org/10.1038/bjc.2012.240

Project Title: Management of breast masses in children and adolescents

Faculty Mentor: Saleem Islam 
Email: saleem.islam@surgery.ufl.edu 

Student: Rylie Frayman
Email: rfrayman@ufl.edu  

Research Project Description:

Breast masses in children and adolescents are rare and ignite significant concerns for patients and their families. While there is more plentiful research with regards to adult patients presenting with breast complaints, there is no set standard for an approach to managing pediatric patients. We wish to establish criteria for when it is most appropriate to recommend observation and rather when it is more suggested to recommend operation to better guide pediatric-surgical management of patients with breast masses.

Pediatric patients tend to have more variable presentations but are almost always found to be benign. It is important to consider the risks and potential complications of operating on the patients especially because their breasts are still being developed in addition to the high likelihood that the mass is benign. It is our hope that this data will help add to the sparse literature on this subject in order to help guide management for future cases.

Since the majority of breast masses presenting from pediatric patients are benign, it is predicted that the work of this project will be able to highlight a reduced need for surgical interventions when it comes to management for this population. Furthermore, with the analysis from this research we hope to be able to establish guidelines that will assist the management of future presentations of pediatric breast masses.

The specific aims of this project are to outline a criterion that helps guide management between observation and surgical operation for pediatric patients presenting with breast masses while adding to the limited literature regarding these cases. It is our hope that through this project we will be able to help decrease overall anxiety in patients and their families, demonstrate the likely reduced need for and/or benefit of surgical interventions and generally help guide management in order to best serve our patients.

References:

1. McLaughlin, C., Gonzalez-Hernandez, J., Bennett, M. and Piper, H., 2018. Pediatric breast masses: an argument for observation. Journal of Surgical Research, 228, pp.247-252.
2. Knell, J., Koning, J. and Grabowski, J., 2016. Analysis of surgically excised breast masses in 119 pediatric patients. Pediatric Surgery International, 32, pp.93-96.
3. Englert, E., Ares, G., Henricks, A., Rychlik, K. and Hunter, C., 2018. Analysis of factors predicting surgical intervention and associated costs in pediatric breast masses: a single center study. Pediatric Surgery International, 34, pp.679-685.
4. Chang, D. and McGrath, M., 2007. Management of Benign Tumors of the Adolescent Breast. Plastic and Reconstructive Surgery, 120(1), pp.13e-19e.
5. Omar, L., Gleason, M., Pfeifer, C., Sharma, P. and Kwon, J., 2019. Management of Palpable Pediatric Breast Masses With Ultrasound Characteristics of Fibroadenoma: A More Conservative Approach. American Journal of Roentgenology, 212, pp.450-455.
6. Kennedy, R. and Boughey, J., 2013. Management of Pediatric and Adolescent Breast Masses. Seminars in Plastic Surgery, 27(1), pp.19-22.

Project Title: Determining iron overload in pediatric cancer survivors

Faculty Mentor: Tung Wynn 
Email: twynn@ufl.edu 

Student: Ethan Holland 
Email: eholland1@ufl.edu 

Research Project Description:

Pediatric cancer survivors are an ever-enlarging population, as rates of cancer diagnosis of all types in pediatrics have been increasing as of 2014.(1) It is estimated that there were 15.5 million cancer survivors living in the United States in 2015, with at least 429,000 pediatric. Advances in cancer therapy have led to 84% survival rate after 5 years in pediatric cancers.(2) The therapies used to cure these cancers cause patients to face unique and sometimes serious health issues that call for long-term management. One example is packed red blood cell transfusion (PRBC) which is commonly given in the supportive care of cancer patients because most chemotherapies can cause myelosuppression and severe anemia. Frequent PRBCare a major cause of iron overload. The body is unable to remove iron beyond its limited capacity, and thus will deposit excess iron in tissues such as the liver, the heart, and the pancreas. The inappropriate deposition of iron eventually interferes with the normal function of these organs, and can lead to complications including transaminitis, cirrhosis, liver failure, hypoinsulinemia, diabetes, cardiac conduction disorders, and heart failure.
The prevalence of HFE gene polymorphisms and mutations associated with hereditary hemochromatosis is generally regarded as common, with previous studies showing the HFE gene is mutated in approximately 85% of individuals known to have hereditary hemochromatosis.(3) Homozygosity and compound heterozygosity are thought to be associated with hereditary chromatosis because these mutations are understood to be autosomal recessive. However, it is often observed that even heterozygous carriers may have abnormally elevated iron studies, even if it is not true hemochromatosis nor iron overload.(4) In addition, it is often reported that people with HFE mutation and polymorphism have increased rates of cancer development such as acute lymphoblastic leukemia (ALL) hepatocellular carcinoma and epithelial ovarian cancer.(5-7) Specifically in children, the HFE mutation has shown associations that may lead to medical conditions later in life such as liver cirrhosis and cardiotoxicity.(5,8)
It is the goal of this study to determine the rate of elevated ferritin levels as a measure of iron overload and hemochromatosis within a pediatric cancer survivor’s population at the University of Florida. It is hoped that this study will help quantify the frequency of transfusion therapy used in the supportive care of cancer patients. This will be correlated with the patient’s diagnosis, the type of cancer that was treated, the types of chemotherapies that were used, and the development of any known iron overload related complications. This information may provide insight into the role that HFE polymorphisms might play in pediatric cancer development, and it may further help to inform those caring for pediatric cancer survivors about the need for routine ferritin monitoring and potential screening for hereditary hemochromatosis before or after treatment.

The primary aim of the study is to determine if the presence of an HFE polymorphism contributes to the elevation of ferritin in the pediatric cancer survivorship population. It is hypothesized that patients with HFE polymorphisms have elevated ferritin levels. These patients have decreased capacity for iron removal due to their hereditary hemochromatosis via HFE gene mutation, so the increased iron burden from cancer treatment should show an increase of ferritin levels.

The primary aim of this study is to determine how HFE polymorphisms impact the rate of elevated ferritin and hemochromatosis in a pediatric cancer survivor population. Secondarily we wish to determine the prevalence of HFE mutations in a pediatric cancer survivor population, evaluate the frequency with which childhood cancer survivors are evaluated for iron overload and HFE mutations, and finally assess the association between HFE mutations and iron overload in the pediatric cancer population.

References:

1. Lewis, D.R., Chen, H.‐S., Cockburn, M.G., Wu, X.‐C., Stroup, A.M., Midthune, D.N., Zou, Z., Krapcho, M.F., Miller, D.G. and Feuer, E.J. (2017), Early estimates of SEER cancer incidence, 2014. Cancer, 123: 2524-2534. doi:10.1002/cncr.30630
2. Childhood Cancer Survivor Study: An Overview. (2018, September 27). Retrieved May 5, 2020 from https://www.cancer.gove/types/childhood-cancers/ccss
3. Feder, J.N. The hereditary hemochromatosis gene (HFE). Immunol Res 20, 175–185 (1999). https://doi.org/10.1007/BF02786472
4. Hollerer, I., Bachmann, A., & Muckenthaler, M. U. (2017). Pathophysiological consequences and benefits of HFE mutations: 20 years of research. Haematologica, 102(5), 809–817. https://doi.org/10.3324/haematol.2016.160432
5. Bacon, B.R., Adams, P.C., Kowdley, K.V., Powell, L.W. and Tavill, A.S. (2011), Diagnosis and management of hemochromatosis: 2011 Practice Guideline by the American Association for the Study of Liver Diseases. Hepatology, 54: 328-343. doi:10.1002/hep.24330
6. Kennedy A, Kamdar K, Lupo P, et al. Examination of HFE association with childhood leukemia risk and extension to other iron regulatory genes. Leukemia Research. 2014;38:1055–60. doi: 10.1016/j.leukres.2014.06.016
7. Gannon, P. O., Medelci, S., Le Page, C., Beaulieu, M., Provencher, D. M., Mes-Masson, A. M., & Santos, M. M. (2011). Impact of hemochromatosis gene (HFE) mutations on epithelial ovarian cancer risk and prognosis. International journal of cancer, 128(10), 2326–2334. https://doi.org/10.1002/ijc.25577
8. Akam-Venkata J, Franco VI, Lipshultz SE. Late Cardiotoxicity: Issues for Childhood Cancer Survivors. Current Treatment Options in Cardiovascular Medicine. 2016 Jul;18(7):47. DOI: 10.1007/s11936-016-0466-6.

Project Title: Historical trends in post-operative opioid prescribing practices in children

Faculty Mentor: Robin Petroze 
Email: Robin.Petroze@surgery.ufl.edu 

Student: Esther Blondeau-Lecomte and Victoria Hoang 
Email:  eblondeaulecomte@ufl.edu; vhoang1@ufl.edu

Research Project Description:

According to the National Institute on Drug Abuse, more than ninety Americans die every day due to opioid overdose. The opioid epidemic began back in 1980, when an article published in the New England Journal of Medicine indicated that addiction was rare in a specific subset of patients who were treated with narcotics. The data was extrapolated and applied generally to all patients, and for many years, opioids were considered safe treatments for chronic pain. In 2007, the federal government filed criminal charges against a pharmaceutical company for claiming that Oxycontin was a safe, less-addictive pain medication. On October 26, 2017, the acting secretary of Health and Human Services declared the opioid crisis a public health emergency. That same year, over 47,000 people died due to opioid overdose. Opioid addiction had become a force that tore apart families due to its high potential of abuse, and many lost their lives.

One of the factors contributing to opioid dependence and addiction is over-prescription of opioids after surgery. Awareness of the opioid crisis as well as national and state legislation that places restrictions on opioid prescription has driven physicians to be more cautious when prescribing opioids. However, no standardized practices have been put in place that outline exactly what types of narcotics and how much should be prescribed following surgery. An obstacle that makes standardized prescription practices difficult is the varying patient response to pain. The specific type of surgery, patient co-morbidities, access to other healthcare, and individual physiology all affect a person’s specific need for pain relief. Few studies have attempted to gather data on how much pain medication is prescribed, how much is used, and how much is needed.

Several pieces of legislation, both statewide and nationally, have placed limitations on opioid prescriptions. The Comprehensive Addiction and Recovery Act was signed into law on July 22, 2016 to combat the opioid epidemic. This law increased awareness of addictive substance use and provided resources for recovery and treatment. Included in the Act was a provision to strengthen prescription drug monitoring programs in individual states, provide services to individuals at risk, and to monitor prescription drug use. On September 2016, the CDC implemented guidelines for prescribing opioids, in addition to Funding for Enhanced State Opioid Overdose Surveillance, which tracks opioid-related overdoses. One of the states funded includes Florida. At a more local level, the Florida Controlled Substances Bill, also known as HB21, Chapter 2018-13, Laws of Florida went into effect on July 1st, 2018. This law placed many restrictions on how much opioid medication physicians can prescribe and made it more difficult for patients to have continuous access to prescribed opioids. On October 2018, Congress signed a bipartisan opioid legislation: HR 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities Act. All of these pieces of legislation both increase awareness of the opioid epidemic, as well as provide measures to limit opioid prescriptions on the provider end, and limit opioid abuse on the patient’s end.

Changes in legislation have decreased the amount of opioid medication prescribed, as suggested by various studies. A 2020 study looking at pharmacy prescription claims for opioids in Florida from 2015 to 2019 found that there was a decrease in hydrocodone and non-schedule II opioid use after implementation of Chapter 2018-13.1 This study, however, did not look at solely at pediatric patients. A 2019 study looked more specifically at prescriptions after surgeries, and indicated that opioid prescriptions were significantly reduced six months after implementation of legislation in Florida.2 This study only included adults 18 years of age or older, and thus the results cannot be generalized to the pediatric population. Although these studies indicate that changes in legislation have led to more controlled opioid use, studies have not been done on pediatric populations, and standardized opioid prescription practices have not yet been formulated.

Within the pediatric population, teenagers are also of particular interest. Several studies have indicated that the group prescribed the most opioids were teenagers, who continued to fill prescriptions months after surgery. A 2018 longitudinal study looked at opioid prescriptions after dental extractions in individuals ages 16-25 in 2015.3 Results suggested that opioid prescriptions in teenagers correlated with an increased likelihood of abuse and dependence in adulthood. Additionally, a 2011 study surveyed middle and high school students, and found that 22% of those who were prescribed opioids misused their medication.4 Those who misused their medications were more likely to abuse other drugs. Teenagers are thus a unique subset of the pediatric population that should be further studied.

A number of studies have indicated the variant nature of opioid prescription patterns in the pediatric population. A 2018 study found that narcotic prescription practices varied greatly for pediatric patients undergoing appendectomies.5 A 2017 study on pediatric ambulatory surgery found that the age of the patient changed not only the probability of analgesics being prescribed, but the type of medication prescribed.6 Furthermore, variations on opioids prescription practices can be found among different surgical specialties. For instance, a study in 2019 evaluated prescription habits of general versus pediatric surgeons and found that pediatric surgeons tended to prescribe less opioids overall after laparoscopic appendectomies.7 Additional studies indicate that prescription patterns are not only highly inconsistent in pediatric operations, but are prescribed in overly-high amounts.8,9 According to a 2015 prospective study, pediatric patients who were prescribed opioids before the 12th grade had a greater change of opioid misuse in adulthood.10 Thus, more research needs to be done to determine standardized opioid prescribing practices in pediatric patients.

References:

1. Hincapie-Castillo, J. M., Goodin, A., Possinger, M.-C., Usmani, S. A., & Vouri, S. M. (2020). Changes in Opioid Use After Florida’s Restriction Law for Acute Pain Prescriptions. JAMA Network Open, 3(2). doi: 10.1001/jamanetworkopen.2020.0234
2. Potnuru, P., Dudaryk, R., Gebhard, R. E., Diez, C., Velazquez, O. C., Candiotti, K. A., & Epstein, R. H. (2019). Opioid prescriptions for acute pain after outpatient surgery at a large public university-affiliated hospital: Impact of state legislation in Florida. Surgery, 166(3), 375–379. doi: 10.1016/j.surg.2019.04.022
3. Schroeder, A. R., Dehghan, M., Newman, T. B., Bentley, J. P., & Park, K. T. (2019). Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Internal Medicine, 179(2), 145. doi: 10.1001/jamainternmed.2018.5419
4. Mccabe, S. E. (2011). Medical Misuse of Controlled Medications Among Adolescents. Archives of Pediatrics & Adolescent Medicine, 165(8), 729. doi: 10.1001/archpediatrics.2011.114
5. Anderson, K. T., Bartz-Kurycki, M. A., Ferguson, D. M., Kawaguchi, A. L., Austin, M. T., Kao, L. S., Lally K. P., Tsao, K. (2018). Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients. Journal of Pediatric Surgery, 53(12), 2374–2377. doi: 10.1016/j.jpedsurg.2018.08.034
6. Cleve, W. C. V., & Grigg, E. B. (2017). Variability in opioid prescribing for children undergoing ambulatory surgery in the United States. Journal of Clinical Anesthesia, 41, 16–20. doi: 10.1016/j.jclinane.2017.05.014
7. Freedman-Weiss, M. R., Chiu, A. S., Solomon, D. G., Christison-Lagay, E. R., Ozgediz, D. E., Cowles, R. A., Caty, M. G., Stitelman, D. H. (2019). Opioid Prescribing Habits of General Versus Pediatric Surgeons After Uncomplicated Laparoscopic Appendectomy. Journal of Surgical Research, 235, 404–409. doi: 10.1016/j.jss.2018.09.085
8. Horton, J. D., Munawar, S., Corrigan, C., White, D., & Cina, R. A. (2019). Inconsistent and excessive opioid prescribing after common pediatric surgical operations. Journal of Pediatric Surgery, 54(7), 1427–1431. doi: 10.1016/j.jpedsurg.2018.07.002
9. Ruan, X., Wu, H., & Kaye, A. D. (2017). Persistent Opioid Use After Major Surgery. JAMA Surgery, 152(4), 411. doi: 10.1001/jamasurg.2016.5655
10. Schroeder, A. R., Dehghan, M., Newman, T. B., Bentley, J. P., & Park, K. T. (2019). Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Internal Medicine, 179(2), 145. doi: 10.1001/jamainternmed.2018.5419

Project Title: Developing a Multi-disciplinary Pathway for Pediatric Appendicitis: A Comprehensive Quality Improvement Project

Faculty Mentor: Robin Petroze 
Email: robin.petroze@surgery.ufl.edu 

Student: Joseph Calpin 
Email: jcalpin@ufl.edu 

Research Project Description:

In the pediatric population, appendicitis is one of the most common causes of acute abdominal pain. Without using imaging, the most reliable signs for ruling in acute appendicitis in children include physical examination findings such as absent or decreased bowel sounds, a positive psoas sign, a positive Rovsing sign, and a positive obturator sign.1 Patients can then be further evaluated combining classic history and exam findings with laboratory analysis using the Pediatric Appendicitis Score, which incorporates eight variables found to be statistically significant in diagnosing pediatric appendicitis. This score can then help physicians stratify patients by risk and guide them toward a plan of care.2

Implementation of interdisciplinary clinical practice guidelines for pediatric appendicitis has been successful at reducing CT utilization while still accurately diagnosing appendicitis.3,4 Although CT scans are very accurate when it comes to diagnosing appendicitis, concerns for the amount of radiation pediatric patients are exposed to have led to efforts to emphasize other factors, such as the Pediatric Appendicitis Score or ultrasonography, in making a diagnosis. Ultrasound as an imaging modality does not expose the patient to any radiation, is much cheaper than a CT, and can often be done at the bedside by the physician (point-of-care). Unfortunately, it has a lower sensitivity compared to CT and is more user dependent. For this reason, clinical practice guidelines dealing with pediatric appendicitis often recommend either point-of-care ultrasound (POCUS) or radiology-performed ultrasound prior to ordering a CT scan. If the ultrasound is read as equivocal, it is often followed by a CT scan to either confirm or rule out acute appendicitis.5-7 One of the main obstacles to using ultrasound is the rate of non-visualized appendix. This finding alone cannot rule out or confirm a diagnosis, but, when combined with a clinical picture and physical exam, it can have a high negative predictive value.8 Overall, standardization of care through utilization of a clinical practice guideline has been shown to decrease the radiation exposure to patients, while still having low negative appendectomy rates, without under-diagnosing acute appendicitis in a pediatric setting.9

By implementing an evidence-based clinical practice guideline for pediatric patients with suspected appendicitis, we can improve outcomes and decrease complications. Many other hospitals and healthcare systems have implemented such clinical practice guidelines and, as a result, have improved the overall quality and efficacy of the care their patients have received.

References:

1. Snyder MJ, Guthrie M, Cagle S. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician. 2018;98(1):25–33.
2. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37(6):877–881. doi:10.1053/jpsu.2002.32893
3. Russell WS, Schuh AM, Hill JG, et al. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care. 2013;29(5):568–573. doi:10.1097/PEC.0b013e31828e5718
4. Aydin D, Turan C, Yurtseven A, et al. Integration of radiology and clinical score in pediatric appendicitis. Pediatr Int. 2018;60(2):173–178. doi:10.1111/ped.13471
5. Ramarajan N, Krishnamoorthi R, Barth R, et al. An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med. 2009;16(11):1258–1265. doi:10.1111/j.1553-2712.2009.00511.x
6. Krishnamoorthi R, Ramarajan N, Wang NE, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011;259(1):231–239. doi:10.1148/radiol.10100984
7. Miano DI, Silvis RM, Popp JM, Culbertson MC, Campbell B, Smith SR. Abdominal CT Does Not Improve Outcome for Children with Suspected Acute Appendicitis. West J Emerg Med. 2015;16(7):974–982. doi:10.5811/westjem.2015.10.25576
8. Nah SA, Ong SS, Lim WX, Amuddhu SK, Tang PH, Low Y. Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children. J Pediatr. 2017;182:164–169.e1. doi:10.1016/j.jpeds.2016.11.062
9. Saucier A, Huang EY, Emeremni CA, Pershad J. Prospective evaluation of a clinical pathway for suspected appendicitis. Pediatrics. 2014;133(1):e88–e95. doi:10.1542/peds.2013-2208

Project Title: UF Healthy Kids Medical Legal Partnership

Faculty Mentor: Rachel Coleman
Email: rmcoleman@peds.ufl.edu 

Student: Emily Loe 
Email: eloe591@ufl.edu 

Research Project Description:

A large body of research has shown that social determinants of health play a significant role in the impact of chronic disease and overall health. Medical Legal Partnerships (MLPs) have emerged as a new way to address psychosocial needs. MLPs include the integration of trained health workers and attorneys into a medical practice to address the specific legal needs of the patient population 3. Health harming legal needs for pediatric patients may include food insecurity or cessation of food benefits 1, heating and utility insecurity 7, or school accommodations 3. MLPs and novel interdisciplinary teams for pediatric patients with chronic diseases have been found to have high retention rates and to improve both quantitative outcomes such as HgA1c 3 as well as enrollee satisfaction 7. In addition to the benefits to the patient, hospitals have been found to have a positive benefit from MLP programs with one hospital finding a 271% return on investment 8. MLPs have been trialed in specialty clinics focusing on patients with sickle cell anemia 5, asthma 4,7, and diabetes 3 as well as those without chronic health conditions6. Given all of this potential benefits to the pediatric population, a pediatric Medical-Legal Partnership was recently started at UF as a pilot program in the Severe Asthma clinic.
Enacting effective MLPs to address legal needs of patients is more complex than simply hiring an attorney. Early in their training, providers may benefit from education on the specific needs that patients are facing. It’s only through exposure and training that providers will have the knowledge needed to address patient’s unique needs. Many medical school programs educate their students about social and medical disparities, but these complex topics can be difficult to translate into practice 2. Residents who received specialized training in advocacy self- reported positive experiences and personal growth 2. As UF Health has a robust Pediatric Residency Program, we have a great opportunity with our MLP to provide a unique educational experience on social determinants of health and how to best address these needs for their patients. By performing an evaluation of our program to date through surveys and chart reviews, we can work to improve and expand the impact of our unique partnership.

Based on previous studies, we aim to demonstrate that patients assisted by our UF Healthy Kids Medical-Legal Partnership will show qualitative improvement in stress demonstrated through pre and post intervention surveys. In addition, we will explore whether patients assisted by our MLP have a decrease in need for health care utilization demonstrated by a decrease in their ER visits and hospitalizations. There likely is significant overlap in the Health Harming Legal Needs seen by different UF Pediatric Specialty Clinics. However, each clinic’s patients likely have unique challenges that are specific to their chronic medical problems. We will detail those similarities and differences through surveys and chart review. In addition, with increasing exposure, clinic staff and residents will gain new insight and exposure to social determinates of health that are specific to their patient populations and become better equipped to help patients access the best resources for their needs in the future. We will survey providers about knowledge they have gained through lectures and hands on experience with our MLP as well as knowledge gaps to see how we can continue to expand the benefits to clinicians.

References:

1. Gilbert AL, Downs SM. Medical legal partnership and health informatics impacting child health: Interprofessional innovations. Journal of interprofessional care. https://www.ncbi.nlm.nih.gov/pubmed/26120893. Published 2015. Accessed April 20, 2020.
2. Klein M, Vaughn LM. Teaching social determinants of child health in a pediatric advocacy rotation: small intervention, big impact. Medical teacher. https://www.ncbi.nlm.nih.gov/pubmed/20795806. Published 2010. Accessed April 20, 2020.
3. Malik FS, Yi-Frazier JP, Taplin CE, et al. Improving the Care of Youth With Type 1 Diabetes With a Novel Medical-Legal Community Intervention: The Diabetes Community Care Ambassador Program. The Diabetes educator. https://www.ncbi.nlm.nih.gov/pubmed/29320934. Published April 2018. Accessed April 20, 2020.
4. Murphy JS, Sandel MT. Asthma and social justice how to get remediation done. American journal of preventive medicine. https://www.ncbi.nlm.nih.gov/pubmed/21767739. Published August 2011. Accessed April 20, 2020.
5. Pettignano R, Caley SB, Bliss LR. Medical-Legal Partnership: Impact on Patients With Sickle Cell Disease. American Academy of Pediatrics. https://pediatrics.aappublications.org/content/128/6/e1482?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token. Published December 1, 2011. Accessed April 20, 2020.
6. Sege R, Preer G, Morton SJ, et al. Medical-Legal Strategies to Improve Infant Health Care: A Randomized Trial. American Academy of Pediatrics. https://pediatrics.aappublications.org/content/early/2015/05/26/peds.2014-2955. Published May 1, 2015. Accessed April 20, 2020.
7. Taylor DR, Bernstein BA, Carroll E, Oquendo E, Peyton L, Pachter LM. Keeping the Heat on for Children’s Health: A Successful Medical-Legal Partnership Initiative to Prevent Utility Shutoffs in Vulnerable Children. Journal of health care for the poor and underserved. https://www.ncbi.nlm.nih.gov/pubmed/26320904. Published August 2015. Accessed April 20, 2020.
8. Teufel JA, Werner D, Goffinet D, Thorne W, Brown SL, Gettinger L. Rural Medical-Legal Partnership and Advocacy: A Three-Year Follow-up Study. Journal of Health Care for the Poor and Underserved. https://muse.jhu.edu/article/474050. Published April 25, 2012. Accessed April 20, 2020.
9. Teufel J, Heller SM, Dausey DJ. Medical-legal partnerships as a strategy to improve social causes of stress and disease. American journal of public health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232103/. Published December 2014. Accessed April 20, 2020.

Project Title: Hemolysis among pediatric patients with heart failure supported by pulsatile para-corporeal ventricular assist devices (VADs) as a bridge-to-transplant

Faculty Mentor: Joseph Philip 
Email: subijo9@ufl.edu 

Student: Emma Powers
Email: emmapowers@ufl.edu  

Research Project Description:

Among patients awaiting a solid-organ transplant, pediatric patients in heart failure needing a heart transplant have the highest mortality rate.1 Essentially no mechanical support existed for pediatric patients, specifically infants and small pediatric patients, awaiting a heart transplant throughout the 1990s and 2000s.2 At the time, the only mechanical support for young pediatric patients as a bridge to transplant was extracorporeal mechanical oxygenation (ECMO) with a 45% survival to transplant.2 Unfortunately, ECMO is a short-term solution, and mortality rate inclines with increasing length of support, especially longer than 14 days.2

In 2012, the Berlin Heart EXCOR was FDA approved to allow for wide use as a pulsatile ventricular assist device (VAD) on pediatric patients with heart failure of all sizes.3 The survival rate of the Berlin Heart EXCOR is higher than ECMO at 77%-92% compared to 39%-64%.1 The Berlin Heart EXCOR allowed for improved management of care of these patients. Despite increasing survival rate, patients with congenital heart disease or children under 10 kg tend to have worse outcomes compared to patients with other causes of heart failure.4,5 In addition, 2/3 of patients <5 kg died while awaiting transplantation while supported by the VAD.6 The research and advancements in the treatment of pediatric patients in heart failure are promising, but many obstacles to the management of pediatric heart failure still exist.

The two categories of VADS used today are continuous and pulsatile VADs. Continuous VADs are commonly used in the adult population while pulsatile VADs are more common among the pediatric population. The complication of hemolysis in adult patients supported by a continuous VAD has been studied, but there is a lack of data on hemolysis in pediatric patients supported by a pulsatile VAD. Additionally, previous studies have shown that there is increased mortality with hemolysis.7 Anecdotal evidence of hemolysis with increased complications in the pediatric population supported by pulsatile VADs has been noted at our institution. The use of pulsatile VADs in the pediatric population is a new technology, so data and research are lacking in this area. Hemolysis in pediatric patients on the Berlin Heart EXCOR needs to be investigated so further research can be done to improve the administration of care.

ypothesis: Hemolysis and inflammation markers are going to be higher in infants than in non-infants supported by para-corporeal pulsatile ventricular assist device, leading to increased end-organ dysfunction and mortality compared to patients who do not develop hemolysis.

Rationale: Hemolysis associated with the support of a continuous flow ventricular assist device increases mortality as noted in previous studies.7 Anecdotally, patients experiencing hemolysis while supported by the pulsatile Berlin Heart EXCOR have worse outcomes, such as increased end-organ dysfunction, especially the liver, and increased mortality due to inflammation causing thrombotic events. Hemolytic anemia leads to an increased need for transfusions during VAD support which potentiates the risk for the later complication of transplant rejection.8 Interestingly, some patients have hemolysis while others do not. Lack of research and data exists evaluating hemolysis in pediatric patients with pulsatile VAD support. The focus of this study is to differentiate the patients with and without hemolysis to identify outcomes and separate possible physiology that increases the risk of hemolysis on pulsatile VADs. Once outcomes are established, research can identify interventions to decrease hemolysis.

References:

1. Almond CSD, Thiagarajan RR, Piercey GE, et al. Waiting list mortality among children listed for heart transplantation in the United States. Circulation. 2009;119(5):717-727.
2. Almond CS, Singh TP, Gauvreau K, et al. Extracorporeal membrane oxygenation for bridge to heart transplantation among children in the United States: analysis of data from the Organ Procurement and Transplant Network and Extracorporeal Life Support Organization Registry. Circulation. 2011;123(25):2975-84.
3. Fraser CD, Jaquiss RD. The Berlin Heart EXCOR Pediatric ventricular assist device: history, North American experience, and future directions. Ann N Y Acad Sci. 2013;1291:96-105.
4. Vanderpluym C, Urschel S, Buchholz H. Advanced therapies for congenital heart disease: ventricular assist devices and heart transplantation. Can J Cardiol. 2013;29(7):796-802.
5. Conway J, St louis J, Morales DL, Law S, Tjossem C, Humpl T. Delineating survival outcomes in children <10 kg bridged to transplant or recovery with the Berlin Heart EXCOR Ventricular Assist Device. JACC Heart Fail. 2015;3(1):70-7.
6. Almond CS, Morales DL, Blackstone EH, et al. Berlin Heart EXCOR pediatric ventricular assist device for bridge to heart transplantation in US children. Circulation. 2013;127(16):1702-11.
7. Ravichandran AK, Parker J, Novak E, et al. Hemolysis in left ventricular assist device: a retrospective analysis of outcomes. J Heart Lung Transplant. 2014;33(1):44-50.
8. Holt S, Donaldson H, Hazlehurst G, et al. Acute transplant rejection induced by blood transfusion reaction to the Kidd blood group system. Nephrol Dial Transplant. 2004;19(9):2403-6.

Project Title: Reducing the Incidence of Complications in Pediatric Patients with Gastrostomy Tubes

Faculty Mentor: Saleem Islam 
Email: saleem.islam@surgery.ufl.edu 

Student: Vanessa Rodriguez 
Email: vrodrig96@ufl.edu 

Research Project Description:

Enteral access is the preferred method of nutritional support for children who cannot acquire adequate nutrition by mouth. Gastrostomy tube placement is one of the most common pediatric surgical procedures. There are different types of surgically placed feeding tubes used: gastrostomy tubes (G-tubes) are inserted into the stomach and gastrojejunostomy tubes (GJ-tubes) are used for patients who cannot tolerate feeding into the stomach. G-tubes inserted into the stomach and held in place by a water filled balloon are the most common types of tubes placed in children.

Numerous studies report significant healthcare costs, inappropriate utilization of hospital resources, and decreased quality of life associated with high rates of non-surgical complications with G-tubes in children. Tube dislodgment, leakage, and associated skin complaints are reported in up to 85% of patients with G-tubes (Goldin, 2016). Patient expenses for G-tube maintenance is estimated at $40,000 annually, not including costs associated with complications, emergency department visits, or hospitalizations (Dempster 2016). A multidisciplinary approach will be implemented to evaluate current practice, update educational resources, and establish standard clinical pathways for children with G-tubes. These efforts will cut costs, increase patient quality of life, and improve utilization of hospital resources

We predict that tube dislodgment and tube site skin complaints will be the most common complaint. Many of these patients are not managed outpatient due to them not having adequate supplies. This information will provide important data to implement future multidisciplinary interventions and future projects to improve the standard practices of caring for pediatric patients with enteral feeding tubes at UF Health. Implementing a clinical standard will minimize unnecessary variation, improve patient outcomes, and decrease costs.

This is a multidisciplinary quality improvement project to evaluate the incidence, most common types, and costs associated with G-tubes in children treated at UF Health. An IRB approved, retrospective review will evaluate our own institutional rate of complications with enteral feeding tubes, and help recognize variables placing patients at risk for presenting to the ED with G-tube complaints. This data will help identify ways to decrease the incidence of ED visits for preventable feeding tube complications in pediatric patients.

References:

1. Abdelhadi RA, Rahe K, Lyman B. Pediatric Enteral Access Device Management. Nutrition in Clinical Practice, 2016; 31(6) 748-761
2. Correa JA, Fallon SC, Murphy KM, et al. Resource utilization after gastrostomy tube placement: defining areas of improvement for future quality improvement projects. J Pediatr Surg 2014; 49:1598-601
3. Cortez AR, Warren PW, Goddard GR, et al. Primary Placement of a Low-profile Gastrostomy Button is Safe and Associated with Improved Outcomes in Children. Journal of Surgical Research 2020: 249, 156-162
4. Dempster R, Burdo-Harman W, Halpin E, et al. Estimated Cost-Effectiveness of Intensive Interdisciplinary Behavioral Treatment for Increasing Oral Intake in Children with Feeding Difficulties. Journal Pediatric Psychology 2016; 41(8), 857-866
5. Goldin, A.B., Heiss, K.F., Hall, M. el al (2016). Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement. J Pediatr 174: 139-45

Project Title: Acceptability of Telemedicine Visits Among Gender Non-Conforming / Transgender Youth Patients and Families

Faculty Mentor: Kristin Dayton
Email: kristinjohnson23@ufl.edu 

Student: Sarah Marini 
Email: sarahmarini@ufl.edu 

Research Project Description:

It is generally a well-accepted reality that transgender and gender non-conforming (TGNC) youth underutilize health care in comparison to their cis-gendered counterparts1,2. This reality has resulted in TGNC youth reporting lower rates of general wellness checkups with their primary care physicians as well as significantly worse health statuses overall1. The reasons for this reality are immense, and many may be predicted. Underutilization of healthcare resources amongst TGNC youth stems from fear of discrimination and mistreatment by healthcare providers2. An already discriminated and marginalized patient population, facing enormous health disparities, TGNC youth often are at an increased risk of facing abuse and PTSD at home from both family and peers, making it even more critical that they receive regular wellness checkups3. Fear of further marginalization, however, by healthcare providers often results in their underutilization of health care resources2. It must also be recognized that TGNC youth with compounding inequities, such as race/ethnicity, may be more vulnerable to worse health outcomes due to the social stressors that are associated, not only, with their gender identity and sexual orientation, but also with their race/ethnicity4.

The COVID-19 pandemic has transitioned much clinical care onto a virtual platform5.
Therefore, telemedicine has become a necessity, and not an alternative for many health care providers as the need to preserve vital personal protective equipment to maintain the health and safety of both patients and providers has become necessary5. Although concerns have been raised on the behalf of both patients and providers that personal connection between provider and patient may be lost over this virtual medium, many patients revere telemedicine visits favorably, citing saved travel time and maintained communication with their providers6.

Because the COVID-19 pandemic, has entirely spearheaded telemedicine into the forefront of clinical care, TGNC youth have also begun seeing their providers via the telemedicine platform7. Recognizing that this is a group of patients that faces immense discrimination and health disparities, providers are concerned about the effects of telemedicine on this already vulnerable population7. Sequeira et al. published an abstract that studied TGNC youth patient perspectives on telehealth for gender-related care7. Our project aims to investigate further TGNC youth patients and their families’ opinions on gender-affirming therapy delivered via a telemedicine platform. Our project also aims to discover further whether the compounding inequities faced by many of TGNC youth, such as race/ethnicity, socio-economic status (SES), or language barriers, might differentiate overall opinions on telemedicine amongst TGNC youth.

Telemedicine is a rapidly evolving virtual platform through which patients will be continuously expected to receive their health care. The COVID-19 pandemic has wholly catapulted the implementation of telemedicine as social distancing orders have taken into effect. Consequently, as the COVID-19 pandemic proceeds, it has become exceedingly apparent that telemedicine will continue to be implemented in the clinical care setting, even after the culmination of the pandemic. Therefore, although this research study does pose its risks to an already vulnerable population group, the risks seem appropriate, in order to decipher how TGNC youth and their families regard receiving their care via telemedicine. The information gathered via this research project will significantly benefit both present and future patients. Understanding how TGNC youth and their families regard telemedicine, as well as deciphering whether these opinions might perhaps differ amongst diverse patient populations within the TGNC community, is vital in this ever new and evolving reality of virtual medicine.

In a matter of weeks, the COVID-19 pandemic has completely transformed clinical practice, designating telemedicine no longer a supplemental resource, but now a necessity. As stay-at-home orders take into effect, many clinicians have had to alter their clinical practice completely onto a virtual platform. Healthcare delivery to transgender youth included. An already vulnerable population that faces immense healthcare disparities, transgender youth have begun seeing their clinicians for gender-affirming therapy via telemedicine. Our project, therefore, aims to survey transgender youth patients, and their families, on their feelings in regard to seeing their providers via telemedicine. Our project aims to ascertain whether patients feel that gender-affirming therapy is delivered adequately via an online platform or whether aspects of their care are not addressed sufficiently via a telemedicine visit. Our project further aims to quantify whether exacerbating inequities within the transgender community, such as race, ethnicity, language barriers, and socio-economic status may distinguish opinions regarding gender-affirming therapy via telemedicine.

References:

1. Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics. 2018;141(3). doi:10.1542/peds.2017-1683
2. Ding JM, Ehrenfeld JM, Edmiston EK, Eckstrand K, Beach LB. A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients. The Joint Commission Journal on Quality and Patient Safety. 2020;46(1):37-43. doi:10.1016/j.jcjq.2019.09.005
3. Roberts AL, Rosario M, Corliss HL, Koenen KC, Austin SB. Childhood Gender Nonconformity: A Risk Indicator for Childhood Abuse and Posttraumatic Stress in Youth. Pediatrics. 2012;129(3):410-417. doi:10.1542/peds.2011-1804
4. Molina Y, Lehavot K, Beadnell B, Simoni J. Racial Disparities in Health Behaviors and Conditions Among Lesbian and Bisexual Women: The Role of Internalized Stigma. LGBT Health. 2014;1(2):131-139. doi:10.1089/lgbt.2013.0007
5. Calton B, Abedini N, Fratkin M. Telemedicine in the Time of Coronavirus. Journal of Pain and Symptom Management. Published online March 31, 2020. doi:10.1016/j.jpainsymman.2020.03.019
6. Patient and Clinician Experiences With Telehealth for Patient Follow-up Care. AJMC. Accessed May 8, 2020. https://www.ajmc.com/journals/issue/2019/2019-vol25-n1/patient-and-clinician-experiences-with-telehealth-for-patient-followup-care
7. Sequeira GM, Kidd K, Coulter RW, et al. 59. Transgender Youth’s Perspectives on Telehealth for Delivery of Gender-Related Care. Journal of Adolescent Health. 2020;66(2):S31-S32. doi:10.1016/j.jadohealth.2019.11.062

Project Title: Understanding the risk of comorbidities in girls with polycystic ovary syndrome

Faculty Mentor: Angelina Bernier
Email: angelina@peds.ufl.edu 

Student: Samantha Korn 
Email: samanthatkorn@ufl.edu 

Research Project Description:

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in women of reproductive age and commonly manifests as menstrual irregularity and increased androgens or androgen effect along with ultrasounds evidence of cystic ovaries. Two of these three conditions are typically necessary to make the diagnosis along with a rule out of other pathologic etiologies. Hyperandrogenism can be evident by physical features or hirsutism, acne, or alopecia or by laboratory testing of adrenal or ovarian androgens such as DHEAS and free testosterone. The most common feature of irregular menses in PCOS can be caused by a lack of ovulation leading to cyst formation on the ovaries, which leads to increased production of androgens. Some women with PCOS do not have ovarian cysts yet still experience the symptoms of PCOS. Diagnosis of PCOS in adolescents is sometimes difficult due to common menstrual irregularity, frequency of cystic ovaries and increased insulin resistance that are common to the peri-menarchal time period. Treatments for PCOS include metformin, a change to a healthier lifestyle, and estrogen therapy.
The cause of PCOS is multifactorial. Many genes in the reproductive pathway play a role, but there is not a current study available confirming a predominant genetic etiology. Obesity and metabolic disease appear to be related to the development and progression of PCOS. However, no study has been carried out in multiple sites to significantly connect these factors with the development of PCOS in an adolescent population. Important comorbidities to examine include insulin resistance, type 2 diabetes, nonalcoholic fatty liver disease, sleep apnea, and decreased quality of life. Screening for these co-morbidities is recommended in adult women.

Although guidelines and recommendations for screening and treatment of PCOS in adult women are readily available, information about screening, risk factors, and targeted therapeutic approaches of PCOS in adolescent females is limited. This limited information regarding co-morbidities is particularly concerning as choices for therapeutic targets may significantly vary based on long-term cardiometabolic predicted outcomes. Thus, a study to collect sufficient evidence in this population by leveraging multiple sites is especially important at this time.

Because of the unknown cause of PCOS, limited information about adolescent PCOS, and significant number of co-morbidities, it is important to collect information on these co-morbidities in adolescent women. Moreover, PCOS often presents first in childhood, and thus it is important to understand it in this younger population. By doing so, one can determine whether or not these co-morbidities are similar to those in adult women, determine more methods of treatment, and potentially find methods of prevention of development of PCOS in adolescent women.

There are two main aims for this project. The first aim is to determine prevalence and incidence of co-morbidities in adolescent females with PCOS from different demographics. The second aim is to determine risk factors for co-morbidities in adolescent females with PCOS in order to determine ways to prevent the development of these co-morbidities.

References:

1. Knochenhauer ES, Key TJ, Kahsar-Miller M, Waggoner W, Boots LR, Azziz R. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. The Journal of clinical endocrinology and metabolism. 1998;83(9):3078-3082.
2. Azziz R, Marin C, Hoq L, Badamgarav E, Song P. Health care-related economic burden of the polycystic ovary syndrome during the reproductive life span. The Journal of clinical endocrinology and metabolism. 2005;90(8):4650-4658.
3. Cree-Green M, Bergman BC, Coe GV, et al. Hepatic Steatosis is Common in Adolescents with Obesity and PCOS and Relates to De Novo Lipogenesis but Insulin Resistance. Obesity (Silver Spring). 2016;24(11):2399-2406.
4. Cree-Green M, Rahat H, Newcomer BR, et al. Insulin Resistance, Hyperinsulinemia, and Mitochondria Dysfunction in Nonobese Girls With Polycystic Ovarian Syndrome. J Endocr Soc. 2017;1(7):931-944.
5. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod. 2018;33(9):1602-1618.
6. Ibanez L, Oberfield SE, Witchel S, et al. An International Consortium Update: Pathophysiology, Diagnosis, and Treatment of Polycystic Ovarian Syndrome in Adolescence. Hormone research in paediatrics. 2017;88(6):371-395.
7. Kakoly NS, Earnest A, Teede HJ, Moran LJ, Joham AE. The Impact of Obesity on the Incidence of Type 2 Diabetes Among Women With Polycystic Ovary Syndrome. Diabetes care. 2019.
8. Lewy VD, Danadian K, Witchel SF, Arslanian S. Early metabolic abnormalities in adolescent girls with polycystic ovarian syndrome. The Journal of pediatrics. 2001;138(1):38-44.
9. Cree-Green M, Bergman BC, Coe GV, et al. Hepatic Steatosis is Common in Adolescents with Obesity and PCOS and Relates to De Novo Lipogenesis but not Insulin Resistance. Obesity (Silver Spring). 2016;24(11):2399-2406.

Project Title: The Breastfeeding Medical Student: What policies are in place to support her breastfeeding goals

Faculty Mentor: Lindsay Thompson 
Email: lathom@ufl.edu 

Student: Sanaz Dovell
Email: sdovell@ufl.edu 

Research Project Description:

The benefits of breastfeeding for both baby and mother have long been established. The American Academy of Pediatrics currently recommends that infants be exclusively breastfed for the first six months of life, and that breastfeeding with supplementary foods should continue for at least one year thereafter (1). However, while 83% of infants born in 2015 started out breastfeeding, less than half of infants were still exclusively breastfed at 3 months, and only 25% of infants were exclusively breastfed at 6 months of age (2).

Physicians play a big role in breastfeeding initiation and the duration of breastfeeding for their patients. Medical schools have strived to improve breastfeeding education of their students in an attempt to improve breastfeeding outcomes (3,4). Knowledge of the benefits of breastfeeding for both the infant and the mother is certainly important for the practicing physician, but positive attitudes towards breastfeeding are equally as important. These attitudes and emotions about breastfeeding often come from personal experiences. Most women attend medical school and go through their medical training during their fertile years, and many women do have children either in medical school or during residency or fellowship trainings. Female physicians and medical students have higher than average breastfeeding initiation rates, which reflects positively on the knowledge and education they received about breastfeeding (5,6). Unfortunately, early unintended weaning rates are also very high for women in this group, and that is reflective of the occupational and training-related barriers that these women face (5–7). Lack of time or an acceptable place to express milk, long work hours, and short maternity leave are among some of the significant barriers that female medical students and residents experience, which results in a shorter breastfeeding duration than they intended (6,7). These mothers who are unable to meet their own breastfeeding goals often have negative emotions about breastfeeding, and these negative emotions do impact the way these physicians interact with their breastfeeding patients (7).

Obstetricians, pediatricians, and physicians in family medicine, amongst others, all play a pivotal role in promoting and encouraging mothers to breastfeed their babies. However, if the physician herself was not able to meet her own breastfeeding goals because policies did not exist to allow her to express milk for her infant while she trained, how likely will she be to promote breastfeeding for her own patients? Proposed policies and calls to action are being published for residents and fellows who wish to breastfeed their infants, but policies geared towards medical students underrepresented (8–10).

Policy changes that support breastfeeding mothers have been shown to positively impact the duration of breastfeeding (11,12). Therefore, it stands to reason that if medical students are afforded adequate access to lactation facilities, time to express milk, and adequate maternity leave, then these mothers are more likely to meet their breastfeeding goals and will have a more positive attitude towards breastfeeding. Physicians with positive attitudes towards breastfeeding will ultimately result in more breastfeeding support for lactating female patients by their physicians

In this project, we seek to

1. Learn what policies are currently in place, if any, for all of the Florida medical schools that support breastfeeding medical students. This includes current infrastructure in place for lactation. For example, the Harrell Medical Education Building at UFCOM already has a lactation room.
2. Assess the feasibility of enacting a policy for medical students, carefully considering the unique nature of the clerkship years compared to the preclinical years.
3. Construct a set of guidelines and policies that medical schools can use to help support their students who wish to breastfeed their children.

References:

1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 129, e827-841 (2012).
2. CDC. 2018 Breastfeeding Report Card. Centers for Disease Control and Prevention https://www.cdc.gov/breastfeeding/data/reportcard.htm (2019).
3. Ogburn, T., Espey, E., Leeman, L. & Alvarez, K. A breastfeeding curriculum for residents and medical students: a multidisciplinary approach. J. Hum. Lact. Off. J. Int. Lact. Consult. Assoc. 21, 458–464 (2005).
4. Kim, Y. J. Important Role of Medical Training Curriculum to Promote the Rate of Human Milk Feeding. Pediatr. Gastroenterol. Hepatol. Nutr. 20, 147–152 (2017).
5. Livingston-Rosanoff, D. et al. Got Milk? Design and Implementation of a Lactation Support Program for Surgeons. Ann. Surg. 270, 31–32 (2019).
6. Cantu, R. M., Gowen, M. S., Tang, X. & Mitchell, K. Barriers to Breastfeeding in Female Physicians. Breastfeed. Med. Off. J. Acad. Breastfeed. Med. 13, 341–345 (2018).
7. Dixit, A., Feldman-Winter, L. & Szucs, K. A. ‘Frustrated,’ ‘depressed,’ and ‘devastated’ pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding support. J. Hum. Lact. Off. J. Int. Lact. Consult. Assoc. 31, 240–248 (2015).
8. Weinstein, D. F., Mangurian, C. & Jagsi, R. Parenting during Graduate Medical Training — Practical Policy Solutions to Promote Change. N. Engl. J. Med. 381, 995–997 (2019).
9. Dixit, A., Feldman-Winter, L. & Szucs, K. A. Parental Leave Policies and Pediatric Trainees in the United States. J. Hum. Lact. Off. J. Int. Lact. Consult. Assoc. 31, 434–439 (2015).
   10.Taylor, J., Macnamara, M., Groskin, A. & Petras, L. Medical student-mothers. R. I. Med. J. 2013 96, 42–45 (2013).
   11.Eren, T., Kural, B., Yetim, A., Boran, P. & Gökçay, G. Breastfeeding experiences of female physicians and the impact of the law change on breastfeeding. Turk Pediatri Arsivi 53, 238–244 (2018).
   12.Steurer, L. M. Maternity Leave Length and Workplace Policies’ Impact on the Sustainment of Breastfeeding: Global Perspectives. Public Health Nurs. Boston Mass 34, 286–294 (2017).

Project Title: Developing a Clinical Guideline for the Management of Pediatric Appendicitis (Part Two: Peri-Operative and Post-Operative Management)

Faculty Mentor: Robin Petroze 
Email: robin.petroze@surgery.ufl.edu 

Student: Tristin Latty 
Email: tlatty@ufl.edu  

Research Project Description:

Acute appendicitis is one of the most common abdominal emergencies in the United States and most common between ages 10-19 years.1 Accurate diagnosis and timely treatment is crucial in reducing additional complications for afflicted patients. However, there is substantial variability between providers in the management of pediatric appendicitis.2 The utilization of multidisciplinary clinical practice guidelines at other institutions has shown to decrease utilization of CT scans, improve diagnostic accuracy, and reduce costs per appendectomy.3-7
The standard treatment for acute appendicitis is a laparoscopic appendectomy performed within the first 24 hours of diagnosis, with a same day discharge being safe for non-perforated appendicitis patients with proper physician education and protocol.8-10 Approximately 25-30% of appendicitis patients present with perforation, which requires a longer hospital admission with increased post-operative complications, increased readmission rates, and increased rates of organ space infection.11-13 Overall, clinical pathways for pediatric appendicitis have shown to decrease resource utilization and decrease costs per patient with improved patient outcomes 14-16. Although patient and family satisfaction outcomes are not well documented in the literature, the utilization of clinical pathways has been linked to increased patient satisfaction in the treatment of other diseases.17-19
Additionally, there is considerable variation in the duration, timing, and spectrum of antibiotics in the management of both perforated and non-perforated appendicitis. A systematic review conducted in 2010 outlines several evidence based guidelines on the use of antibiotics in the setting of pediatric appendicitis.20,21 The inclusion of antibiotic standardization is crucial as it has been associated with reduced post-operative abscesses, decreased readmission rates, and reduced hospital stay in perforated appendicitis clinical guidelines.14,16.

The management of pediatric appendicitis is highly variable among providers, and system-wide utilization of an evidence-based clinical guideline has shown to improve patient outcomes and reduce cost.3 We hypothesize that the implementation of a multi-disciplinary, evidence-based clinical guideline through a targeted, locally-adapted approach will improve outcomes and reduce costs for pediatric appendicitis patients.

The overall goal is to develop a locally-adapted clinical guideline to improve outcomes and reduce costs in the management of pediatric appendicitis. A guideline has to be developed initially by surveying the current approaches in managing pediatric appendicitis in all levels of care, and analyzing the strengths and weaknesses of all feasible strategies. The effectiveness of the implemented standardized guideline will be analyzed through a comparison of key outcomes to a retrospective cohort. Specifically our objectives are to:
1) Survey current approaches in the peri-operative and post-operative management of pediatric appendicitis
2) Identify benefits and barriers to the implementation of an evidence-based clinical guideline
3) Develop a locally adapted clinical guideline, which includes:
a. Standardizing operative reporting of pediatric appendicitis
b. Establishment of criteria for total parenteral nutrition, imaging, and invasive procedures (eg. post-operative abscess drainage procedures)
c. Standardization of peri-operative and post-operative antibiotic use
d. Develop multidisciplinary protocol for post-operative management of appendicitis
e. Develop patient education material for same-day discharge after simple appendicitis
4) Evaluate outcomes and effectiveness following standardization by comparing to a historical cohort

References:

1. Anderson JE, Bickler SW, Chang DC, Talamini MA. Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995–2009. World J Surg. 2012;36(12):2787–2794.
2. Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: a survey of North American Pediatric Surgeons. J Pediatr Surg. 2004 Jun;39(6):875-9
3. Willis ZI, Duggan EM, Bucher BT, et. al. Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis. JAMA Surg. 2016 May 18;151(5)
4. Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. May 2017;24(5):523-551.
5. Schoel L, Maizlin, II, Koppelmann T, et al. Improving imaging strategies in pediatric appendicitis: a quality improvement initiative. J Surg Res. Oct 2018;230:131-136.
6. Russell WS, Schuh AM, Hill JG, et al. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care. May 2013;29(5):568-573.
7. Wagenaar AE, Tashiro J, Wang B, et al. Protocol for suspected pediatric appendicitis limits computed tomography utilization. J Surg Res. Nov 2015;199(1):153-158.
8. Aguayo P, Alemayehu H, Desai AA, Fraser JD, St Peter SD. Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis. J Surg Res. Jul 2014;190(1):93-97.
9. Cameron DB, Williams R, Geng Y, et al. Time to appendectomy for acute appendicitis: A systematic review. J Pediatr Surg. Nov 20 2017.
10. Gee KM, Jones RE, Nevarez N, McClain LE, Wools G, Beres AL. No pain is gain: A prospective evaluation of strict non-opioid pain control after pediatric appendectomy. J Pediatr Surg. 2020 Feb 27
11. Cheong LH, Emil S. Determinants of appendicitis outcomes in Canadian children. J Pediatr Surg. May 2014;49(5):777-781.
12. Cheong LH, Emil S. Outcomes of pediatric appendicitis: an international comparison of the United States and Canada. JAMA Surg. Jan 2014;149(1):50-55.
13. Gerard RR, Kielhorn BA, Petersen B, Mullard AJ, McCahill LE. Post-operative management of perforated appendicitis: Can clinical pathways improve outcomes?. Am J Surg. 2018 Apr;215(4)
14. Knott EM, Gasior AC, Ostlie DJ, Holcomb GW, 3rd, St Peter SD. Decreased resource utilization since initiation of institutional clinical pathway for care of children with perforated appendicitis. J Pediatr Surg. Jun 2013;48(6):1395-1398.
15. Yousef Y, Youssef F, Homsy M, et al. Standardization of care for pediatric perforated appendicitis improves outcomes. J Pediatr Surg. Dec 2017;52(12):1916-1920.
16. Warner BW, Kulick RM, Stoops MM, Mehta S, Stephan M, Kotagal UR. An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost. J Pediatr Surg. 1998 Sep;33(9):1371-5.
17. Hussain ZI, Lim M, Stojkovic S. Role of clinical pathway in improving the quality of care for patients with faecal incontinence: A randomised trial. World J Gastrointest Pharmacol Ther. 2017;8(1):81–89. doi:10.4292/wjgpt.v8.i1.81
18. Hoverman JR, Neubauer MA, Jameson M, Hayes JE, Eagye KJ, Abdullahpour M, Haydon WJ, Sipala M, Supraner A, Kolodziej MA, Verrilli DK. Three-Year Results of a Medicare Advantage Cancer Management Program. J Oncol Pract. 2018 Apr;14(4)
19. Kurtin P, Stucky E. Standardize to excellence: improving the quality and safety of care with clinical pathways. Pediatr Clin North Am. 2009 Aug;56(4):893-904.
20. Sawyer RG, Claridge JA, Nathens AB, et. al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21):1996-2005.
21. Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2010 Nov;45(11)

Project Title: Characterization of clinical features and outcomes of pediatric surgical patients diagnosed with gastroparesis and/or biliary dyskinesia

Faculty Mentor: Saleem Islasm 
Email: saleem.islam@surgery.ufl.edu 

Student: Michelot Michel 
Email: mmichel5@ufl.edu 

Research Project Description:

Gastroparesis (GP) is a functional disease associated with delayed gastric emptying, nausea, vomiting, and abdominal pain (1,2). Biliary dyskinesia (BD) on the other hand is a functional gallbladder disease that is characterized by many of the same symptoms and clinical features associated with GP (3,4). These overlapping symptoms include but are not limited to epigastric pain, nausea, and vomiting in the absence of a mechanical/physical obstruction (5). GP and BD are well described in adults with common causes being diabetes mellitus or a post-surgical complication (4). Their etiologies are far less understood in pediatric patients with most observed cases being idiopathic (6).

The diagnosis is made after the exclusion of other causes of abdominal pain such as mechanical blockage, interpretation of laboratory blood tests, imaging studies, and nuclear scintigraphy tests (6,7). Treatment options for GP and BD can encompass conservative management via dietary modifications, medical management with prokinetic agents, surgical interventions, and gastric stimulation (6,7,8). Unfortunately, it has previously been shown that up to 52% of children who undergo surgical removal of the gallbladder continue to have significant symptoms (5,9). Furthermore, a previous study showed that up to 57% of children diagnosed with BD also had concomitant GP5. Children with both GP and BD are more likely to experience worse clinical outcomes and symptoms refractory to treatment compared to those that were diagnosed with BD alone (5).

There is currently little consensus on how to best manage symptoms and stratify children for more tailored treatment. The challenges associated with properly diagnosing and successfully treating these syndromes have resulted in significant morbidity in this patient population. This highlights the importance of our retrospective study to better describe the clinical features, related symptoms, associations, and relevant outcomes of patients with either BD, GP, or BD with concomitant GP. Potentially leading to improved risk stratification and establishing treatment guidelines.

As a tertiary referral hospital system, UF Health has diagnosed, treated, and followed up with numerous pediatric cases of GP, BD, and BD with concomitant GP. This provides an avenue to conduct a retrospective review to better characterize the clinical features, related symptoms, associations, and relevant outcomes of patients with GP and BD. Despite limited evidence, current literature has highlighted specific clinical variables that are associated with varying outcomes and symptom relief (5). It is, therefore, reasonable to assume that our current study can provide further insight into these associations.

The specific aims for this study are: (1) Describe the clinical features, associations, symptoms, and outcomes of UF Health pediatric patients diagnosed with either GP, BD, or both BD and GP; (2) Compare the clinical features and outcomes of patients that have either GP or BD alone versus patients diagnosed with both.

References:

1. Sullivan A, Temperley L, Ruban A. Pathophysiology, Aetiology and Treatment of Gastroparesis. (2020). Dig Dis Sci. 2020;10.1007/s10620-020-06287-2. doi:10.1007/s10620-020-06287-2
2. Waseem, S., Islam, S., Kahn, G., Moshiree, B., & Talley, N. J. (2012). Spectrum of gastroparesis in children. Journal of Pediatric Gastroenterology and Nutrition, 55(2), 166-172. https://doi.org/10.1097/MPG.0b013e31824cf06e
3. Santucci, N. R., Hyman, P. E., Harmon, C. M., Schiavo, J. H., & Hussain, S. Z. (2017). Biliary Dyskinesia in Children: A Systematic Review. Journal of pediatric gastroenterology and nutrition, 64(2), 186–193. https://doi.org/10.1097/MPG.0000000000001357
4. Simon DA, Friesen CA, Schurman JV and Colombo JM (2020) Biliary Dyskinesia in Children and Adolescents: A Mini Review. Front. Pediatr. 8:122. doi: 10.3389/fped.2020.00122
5. Chumpitazi, B. P., Malowitz, S. M., Moore, W., Gopalakrishna, G. S., & Shulman, R. J. (2012). Concomitant gastroparesis negatively affects children with functional gallbladder disease. Journal of pediatric gastroenterology and nutrition, 54(6), 776–779. https://doi.org/10.1097/MPG.0b013e3182455cf9
6. Waseem, S., Moshiree, B., & Draganov, P. V. (2009). Gastroparesis: current diagnostic challenges and management considerations. World journal of gastroenterology, 15(1), 25–37. https://doi.org/10.3748/wjg.15.25
7. Cotton P., et al. (2016). Gallbladder and Sphincter of Oddi Disorders. Gastroenterology, Volume 150, Issue 6, 1420 – 1429.e2
8. Lacy, B. E., & Weiser, K. (2005). Gastric motility, gastroparesis, and gastric stimulation. The Surgical clinics of North America, 85(5), 967–vii. https://doi.org/10.1016/j.suc.2005.05.005
9. Arthur, L. E., Slattery, L., & Richardson, W. (2018). Tailored approach to gastroparesis significantly improves symptoms. Surgical endoscopy, 32(2), 977–982. https://doi.org/10.1007/s00464-017-5775-7

Project Title: Implementing a Quality of Life Screening Tool in the Clinical Setting

Faculty Mentor: Anastasia Albanese-O’Neill 
Email: aalbanese@ufl.edu 

Student: Rebecca Oyetoro 
Email: becca.toro01@ufl.edu   

Research Project Description:

Type 1 diabetes (T1D) is a chronic disease that can occur at any age but is more common in children and young adults. In type 1 diabetes, the immune system destroys insulin-producing cells (beta cells) in the pancreas. Insulin is a hormone that is used to move glucose into the body’s cells as fuel. When the body lacks this machinery, glucose builds up in the blood and the cells starve. The buildup of glucose in the bloodstream can cause dehydration, weight loss, diabetic ketoacidosis, nerve damage, and cardiovascular diseases.
Individuals must have knowledge of appropriate diabetes management. Diabetes education is linked to better glycemic outcomes. In order to manage T1D, individuals need to perform many daily tasks to achieve clinical targets, including administer insulin (via pump or injection), monitoring glucose, managing acute complications (hypo- and hyperglycemia), maintain a healthy diet, exercise, and other self-care behaviors. Management is intensive, and there is a high risk of burnout. Monitoring quality of life and diabetes distress levels periodically can alert the diabetes care team when a patient is at risk for burnout and allow for intervention in a timely manner.
UF Health, under a Disease Management Contract with the Florida Department of Health/CMS, will implement a quality of life (QoL) assessment process for pediatric patients ages 8-11 years with diabetes and their parent caregivers. QoL is a subjective, integrative model that represents a standard level for life satisfaction, including emotional status, physical activities, and social well-being. The area of health-related quality of life (HRQOL) assesses QoL and its correlation with an individual’s health status. It measures population health, life expectancy rate, causes of death, and focuses on the disease impact on overall QoL. Diabetes-specific HRQOL can be helpful in screening individuals with T1D and their families to improve patient care and provide significant conclusions that can influence treatment. We will implement this screening process in a pediatric diabetes clinic to assess quality life to determine barriers to optimal glycemic outcomes and challenges to QoL.

A QoL assessment in EPIC will help identify diabetes-related challenges in pediatric patients ages 8-11 years with diagnosed T1D. Assessing diabetes and addressing QoL will result in improved clinical outcomes by promoting patient-centered care and improving QoL for patients with T1D. Quality improvement also improves population health by addressing the overall quality of care, reducing racial disparities, and other inequities in diabetes outcomes.

References:

1. Hilliard, Marisa., et al. “Assessing Health-Related Quality of Life in Children and Adolescents with Diabetes: Development and Psychometrics of the Type 1 Diabetes and Life (T1DAL) Measures.” Journal of Pediatric Psychology, Volume 45, Issue 3, April 2020, Pages 328–339, https://doi.org/10.1093/jpepsy/jsz083

Project Title: Review of complications of central venous catheters in pediatric patients

Faculty Mentor: Daniel Zhang
Email: danielnzhang@ufl.edu 

Student: Moiz Mustafa 
Email: moiz.mustafa@surgery.ufl.edu

Research Project Description:

Central venous catheters are critical in the treatment of many disease processes and for patients of any age. These catheters can be placed as bedside procedures, in the operating room, or in the interventional suites. Unfortunately, along with the benefits of these catheters, they do carry risks. These risks may be at the time of placement, for the duration of catheter presence, or even at the time of removal. These risks, or complications, pose patient harm as well as additional costs and use of hospital resources. This study aims to study our institution’s pediatric patient population for complications of central venous catheters, in an effort to identify areas for improvement and to mitigate these risks and reduce complications.

The knowledge gained from this study will help direct patient care protocols for the management of central venous catheters. These may include factors related to the placement of catheters, maintenance and management of these catheters once in place, as well as anticipation of complications with removal or that lead to removal of these catheters. In addition, this study aims to look at the general pediatric population (<18 years) and lessons learned from it are applicable to a wide patient population.

Central venous catheters can be placed, maintained, and removed safely with the implementation of appropriate protocols. Developing such protocols requires the thorough study of complications associated with central venous catheters in the patient population on whom these protocols are applied. Current central venous catheter care protocols at UF Health are based on either older data or data not generalizable to our patient population. We hypothesize that a retrospective study of the use of central venous catheters in our pediatric population can provide new knowledge that can be used to modify our current care protocols. Though not within the scope of this retrospective study, the new care protocols that can result from the knowledge gained from this study can be used to reduce complications and costs associated with central venous catheters. This is keeping in line with the UF Health Big Aims Patient Safety Goals: reduce harm, reduce variation in care, enhance the patient experience, and transform our culture.

Our specific aims are focusing on three phases of central venous catheter use: 1) insertion, 2) maintenance, and 3) removal. Regarding insertion, we aim to study 1) the rates of bleeding and need for blood product transfusions to prevent or treat bleeding, 2) the types of catheters selected and location for intended use, and 3) short-term complications such as surgical site infections and wound breakdown. Regarding maintenance, we aim to study 1) effect of catheter repair procedures on rates of infection, 2) effect of catheter clots and/or use of TPA on rates of infection, 3) effect of catheter blood draws on rates of infection for clots, and 4) effect of age / duration of catheter on rates of infection. Regarding removal, we aim to study 1) indications for removal, 2) effect of age / duration of catheter on rates of breakage of catheter during removal, and 3) effect of type / location of catheter on breakage complication.

References:

1. Thakarar K, Collins M, Kwong L, Sulis C, Korn C, Bhadelia N. The role of tissue plasminogen activator use and systemic hypercoagulability in central line-associated bloodstream infections. Am J Infect Control. 2014;42(4):417‐420. doi:10.1016/j.ajic.2013.11.016
2. Rowan CM, Miller KE, Beardsley AL, et al. Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections. Pediatr Crit Care Med. 2013;14(3):306‐309. doi:10.1097/PCC.0b013e318271f48a
3. Donnellan J, Smith CE, John P, Amaral JG. Is Routine Preprocedural Bloodwork Needed for Elective Central Venous Access Device Removals in Children without Bleeding Dyscrasias?. J Vasc Interv Radiol. 2020;31(2):276‐281.e1. doi:10.1016/j.jvir.2019.10.012
4. Ullman AJ, Bulmer AC, Dargaville TR, Rickard CM, Chopra V. Antithrombogenic peripherally inserted central catheters: overview of efficacy and safety. Expert Rev Med Devices. 2019;16(1):25‐33. doi:10.1080/17434440.2019.1555466
5. Alshafei A, Tareen F, Maphango N, White D, O’Connor B, Sriparan T. Open tunneled central line insertion in children – External or internal jugular vein?. J Pediatr Surg. 2018;53(11):2318‐2321. doi:10.1016/j.jpedsurg.2018.07.004
6. Beard L, Levek C, Hwang S, Grover T. Prediction of Nonelective Central Venous Catheter Removal in Medically Complex Neonates. Pediatr Qual Saf. 2019;4(4):e179. Published 2019 Aug 5. doi:10.1097/pq9.0000000000000179
7. Idowu O, Brown J, Kim S, Kim S. Mechanics of a stuck central venous catheter removal. J Pediatr Surg. 2016;51(5):872‐875. doi:10.1016/j.jpedsurg.2016.04.001

Project Title: A Rapid Review of Neonatal Outcomes Associated with Maternal Infection with SARS-CoV-2

Faculty Mentor: Sonja Rasmussen
Email: sonja.rasmussen@peds.ufl.edu 

Student: Daniel Valladares 
Email: dvalladares@ufl.edu 

Research Project Description:

The first confirmed case of SARS-CoV-2 was reported in the United States in late January 2020.1 With the uncertainty of a new virus coming to the United States, vulnerable populations, such as pregnant women, began to be monitored. Recent outbreaks have suggested that pregnant women can be at increased risk for complications, as seen with H1N1 influenza in 2009, or their neonates might be at increased risk for birth defects because of intrauterine transmission of the virus, as seen with the Zika virus. Up until early March, 31 mothers tested positive for SARS-CoV-2 with none of their infants testing positive.2 However, on March 26, three papers were posted online suggesting the possibility of intrauterine transmission. In the first paper, three babies were found to have positive nasopharyngeal and anal swabs for SARS-CoV-2 on days two and four of life.3 The second and third papers reported a total of three infants who were IgM positive.4,5 Since IgM is thought not to cross the placenta, these papers raised the possibility that SARS-CoV-2 crosses the placenta. With the newfound possibility of intrauterine transmission, this study will look to review the current literature on the intrauterine transmission of SARS-CoV-2 to assess the risk factors that may contribute to transmission.

Data from the 2009 H1N1 influenza suggests that even when a virus does not cross the placenta, neonates can be at increased risk of adverse outcomes such as preterm birth, low birthweight, and low Apgar scores, particularly in women who are critically ill.6 Thus, we will also review data on neonatal outcomes among babies born to women infected with SARS-CoV-2 during pregnancy.

We hypothesize that SARS-CoV-2 increases the risk of adverse outcomes in the newborn, especially among women who are critically ill during pregnancy. We expect to see an increased risk of adverse outcomes based on prior research on other viruses such as the 2009 H1N1 influenza, which increased a woman’s risk of pregnancy complications, and the Zika virus, which increased the risk of birth defects.

References:

1. Holshue, M., DeBolt, C., Lindquist, S., Lofy, K., Wiesman, J., Bruce, H., Spitters, C., Ericson, K., Wilkerson, S., Tural, A., Diaz, G., Cohn, A., Fox, L., Patel, A., Gerber, S., Kim, L., Tong, S., Lu, X., Lindstrom, S., Pallansch, M., Weldon, W., Biggs, H., Uyeki, T. and Pillai, S., 2020. First Case of 2019 Novel Coronavirus in the United States. New England Journal of Medicine, 382(10), pp.929-936.
2. Karimi-Zarchi, M., Neamatzadeh, H., Dastgheib, S., Abbasi, H., Mirjalili, S., Behforouz, A., Ferdosian, F. and Bahrami, R., 2020. Vertical Transmission of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review. Fetal and Pediatric Pathology, pp.1-5.
3. Zeng, L., Xia, S., Yuan, W., Yan, K., Xiao, F., Shao, J. and Zhou, W., 2020. Neonatal Early-Onset Infection With SARS-Cov-2 In 33 Neonates Born To Mothers With COVID-19 In Wuhan, China.
4. Dong, L., Tian, J., He, S., Zhu, C., Wang, J., Liu, C. and Yang, J., 2020. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA,.
5. Zeng, H., Xu, C., Fan, J., Tang, Y., Deng, Q., Zhang, W. and Long, X., 2020. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA,.
6. Newsome, K., Alverson, C., Williams, J., McIntyre, A., Fine, A., Wasserman, C., Lofy, K., Acosta, M., Louie, J., Jones-Vessey, K., Stanfield, V., Yeung, A. and Rasmussen, S., 2019. Outcomes of infants born to women with influenza A(H1N1)pdm09. Birth Defects Research, 111(2), pp.88-95.