Implementing Mental Health Screening for Adolescent Hematology and Oncology Patients: A Quality Improvement Initiative.

Purpose: Adolescents and young adults (AYA) with chronic illnesses experience an increase in mental health concerns. A mental health screening (MHS) process for hematology and oncology patients was implemented in a single institution. The quality improvement project was conducted to integrate a MHS process, educate providers about the importance of mental health in this patient population, and evaluate the process. Methods: The COM-B (capability, opportunity, motivation-behavior) model for behavior change was used to inform strategic planning and Plan-Do-Study-Act (PDSA) methodologies for process improvement. Retrospective chart reviews and surveys were conducted to determine missed screening rates and providers' perceptions, knowledge, attitudes, and skills of the MHS process. Results: Of 334 eligible patient encounters, the missed screening rate was 15.0%, the overall error rate of completing the screening was 3.8%, the error rate of completing the suicide or self-harm indicator was 2.6%, and the missed medical social worker touch point was 4.8%. Conclusion: The rising rates of mental health concerns in AYA hematology and oncology patients call for streamlined MHS processes to improve the identification of patients who may need intervention and services. Processes should be tailored to workflows and available resources. Future PDSA cycles will include providing dedicated nursing education and determining the cost needed to meet the rising mental health needs of the AYA hematology and oncology population.

Current practices in pediatric hospital-acquired thromboembolism: Survey of the Children's Hospital Acquired Thrombosis (CHAT) Consortium.

Background: A rise in hospital-acquired venous thromboembolism (HA-VTE) in children has led to increased awareness regarding VTE prophylaxis and risk assessment. Despite no consensus exists regarding these practices in pediatrics. Objective: To describe common practices in VTE prophylaxis, VTE risk assessment models, and anticoagulation dosing strategies in pediatric hospitals that are members of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. Methods: An electronic survey of 44 questions evaluating practices surrounding pediatric HA-VTE risk assessment and prevention was distributed between August 9, 2021, and August 30, 2021, to the primary investigators from the 32 institutions within the CHAT Consortium. Results: The survey response rate was 100% (n = 32). In total, 85% (n = 27) of the institutions assess HA-VTE, but only 63% (n = 20) have formal hospital guidelines. Within the institutions with formal guidelines, 100% (n = 20) include acute systemic inflammation or infection and presence of a central venous catheter (CVC) as risk factors for VTE. Pharmacologic prophylaxis is prescribed at 87% (28) of institutions, with enoxaparin being the most frequent (96%, n = 27). Variability in responses persisted regarding risk factors, risk assessment, thromboprophylaxis, dosing of prophylactic anticoagulation or anticoagulant drug monitoring. A majority of providers were comfortable providing thromboprophylaxis across all age groups. In addition, the global coronavirus disease 2019 increased the providers' use of prophylactic anticoagulation 78% (n = 25). Conclusion: Practices among institutions are variable in regard to use of HA-VTE prophylaxis, risk assessment, or guideline implementation, highlighting the need for further research and a validated risk assessment model through groups like the CHAT Consortium.

Utilizing learning communities to deliver an integrated undergraduate medical education curriculum.

AIM: Learning communities (LCs) have been identified as a structure to support student wellness as well as create a positive learning environment and have been increasingly adopted in undergraduate medical education (UGME). In 2016, Michigan State University College of Human Medicine made curricular changes which integrated basic, social, and clinical sciences. One of the major strategies adopted to deliver this integrated curriculum was to create LCs that served as a central scaffold for students' academic development. Our primary aim is to describe how the school utilized LC faculty to deliver this core integrated curriculum. METHODS: Students were surveyed about their perceptions of the effectiveness of the LCs in delivering an integrated science curriculum. Student academic performance in the new curriculum was compared to that of students from the legacy curriculum as a measure of the effectiveness of the curricular changes. RESULTS: The percentage of students in each class who responded to surveys ranged between 78.7% and 95.8%. Mean Likert responses (1 = strongly disagree; 5 = strongly agree) for statements 'the Faculty Fellow is effective in helping me learn the scholar group content', 'the Faculty Fellow is an effective teacher in our scholar group', and 'the Faculty Fellow is well prepared for our scholar group' ranged from 4.37 to 4.78, 4.72 to 4.76, and 4.81 to 4.86, respectively. In addition, a comparison of summative exam scores of the new curriculum's students to the legacy curriculum's students demonstrated comparable or better performances in the new curriculum. CONCLUSIONS: Utilizing LCs to deliver an integrated science curriculum is an underutilized strategy in UGME. Surveys on student satisfaction and academic performance are encouraging. Additional outcome measures are planned to continually evaluate this innovative multifaceted integration.

Antithrombin III Supplementation in a Premature Infant: Is There a Target Antithrombin Level?

The optimal antithrombin (AT) activity for low-molecular-weight heparin efficacy and the benefits of antithrombin III (ATIII) supplementation in premature infants diagnosed with venous thromboembolism are unknown. Currently, there are no neonatal-specific guidelines directing the appropriate target AT activity during supplementation. This case report describes a critically ill premature infant with a progressive, occlusive inferior vena cava thrombus who received supplemental ATIII during enoxaparin treatment. The patient did not achieve therapeutic anti-Xa levels despite increasing enoxaparin dosing to 3 mg/kg every 12 hours. ATIII supplementation sufficient to attain an AT activity of >40%, in combination with an enoxaparin dosing of >2 mg/kg every 12 hours, was needed to achieve therapeutic anti-Xa levels. Future large studies are needed to determine if there is an optimal target AT activity for critically ill premature infants.

Pituitary sellar spine in a pediatric patient with diabetes insipidus.

A sellar spine is a midline bony spur arising from the ventral aspect of the dorsum sellae. Representing a remnant of the anterior notochord, it is often an incidental finding and thought to be of no clinical significance. However, it has recently been suggested that a potential association may exist between sellar spine and pediatric pituitary endocrinopathies, possibly caused by deformation of the developing pituitary gland by the sellar spine. To our knowledge, this is the first case report demonstrating an association between sellar spine and clinical diabetes insipidus.

Virus-induced genetics revealed by multidimensional precision medicine transcriptional workflow applicable to COVID-19.

Precision medicine requires the translation of basic biological understanding to medical insights, mainly applied to characterization of each unique patient. In many clinical settings, this requires tools that can be broadly used to identify pathology and risks. Patients often present to the intensive care unit with broad phenotypes, including multiple organ dysfunction syndrome (MODS) resulting from infection, trauma, or other disease processes. Etiology and outcomes are unique to individuals, making it difficult to cohort patients with MODS, but presenting a prime target for testing/developing tools for precision medicine. Using multitime point whole blood (cellular/acellular) total transcriptomics in 27 patients, we highlight the promise of simultaneously mapping viral/bacterial load, cell composition, tissue damage biomarkers, balance between syndromic biology versus environmental response, and unique biological insights in each patient using a single platform measurement. Integration of a transcriptome workflow yielded unexpected insights into the complex interplay between host genetics and viral/bacterial specific mechanisms, highlighted by a unique case of virally induced genetics (VIG) within one of these 27 patients. The power of RNA-Seq to study unique patient biology while investigating environmental contributions can be a critical tool moving forward for translational sciences applied to precision medicine.

Reduced dosing of enoxaparin for venous thromboembolism in overweight and obese adolescents: a single institution retrospective review.

BACKGROUND: The global obesity epidemic has created new challenges, including venous thromboembolisms (VTE) in obese adolescents. The data on whether to reduce the dose of low-molecular heparin in obese adults is conflicting, and information on adolescent patients is scarce. OBJECTIVES: Our primary goal was to describe dosing, anti-Xa levels, and outcomes of overweight and obese adolescents who received reduced doses of enoxaparin at the initiation of therapy. The secondary goal was to compare their outcomes to overweight and obese adolescents who received standard 1 mg/kg dosing to determine if future trials for dose reduction are warranted. PATIENTS/METHODS: We performed a retrospective cohort study of overweight and obese patients between the ages of 12 and 18 years old diagnosed with VTE who were treated with reduced dosing (RD) of enoxaparin, comparing their dosing, anti-Xa levels, and outcomes to overweight and obese adolescents who received standard dosing (SD). RESULTS: RD patients (n=19) achieved therapeutic mean initial anti-Xa levels that were similar to SD patients (n=11). Of the RD patients, 53% did not require dose adjustments during treatment. Two RD patients had thrombus progression. A total of 25 patients ultimately completed therapy with RD. CONCLUSIONS: Future trials are warranted to evaluate the efficacy and safety of reduced dosing of enoxaparin to treat overweight and obese adolescents with VTE.

Tumefactive intracranial presentation of precursor B-cell acute lymphoblastic leukemia.

In children, leukemia is the most common malignancy, and approximately 75% of leukemias are acute lymphoblastic leukemia (ALL). Central nervous system leukemia is found at diagnosis in fewer than 5% of children with ALL. Leukemic intracranial masses have been described with acute myeloid leukemia, but ALL presenting as a mass lesion is rare. We describe a unique case of an intracranial confirmed precursor B cell (pre-B) ALL mass in a 13-year-old girl that was diagnosed by brain CT, MRI and cerebral angiography, and confirmed by biopsy. This report details pertinent history and distinguishing imaging features of an intracranial ALL tumefaction.

Expression of EWS-ETS fusions in NIH3T3 cells reveals significant differences to Ewing's sarcoma.

Ewing's sarcomas contain specific chromosomal translocations that fuse EWS to ETS family members, including FLI, ERG, FEV, ETV1 and ETV4. Prior work has suggested that functional differences exist between some of these EWS-ETS fusions. However, as the cell of origin of Ewing's sarcoma is unknown, this prior work was conducted in NIH3T3 cells, which have not been validated as an appropriate model for the study of EWS-ETS fusions. To determine if NIH3T3 cells are a good model for Ewing's sarcoma, we introduced all five EWS-ETS fusions into these cells, and analyzed their phenotypes and gene expression patterns. EWS-FLI, EWS-ERG, and EWS-FEV caused NIH3T3 cells to exhibit anchorage independent growth whereas EWS-ETV1 and EWS-ETV4 did not. In contrast, all the EWS-ETS fusions induced tumor formation in a xenograft model. We defined the core transcriptional profile of the EWS-ETS fusions using cDNA microarrays, and compared these to data derived from patient-derived Ewing's sarcoma cell lines. The NIH3T3 model did not recapitulate the gene expression pattern of bona fide Ewing's sarcoma. Based on these results, we conclude that while there may be functional differences between the various EWS-ETS fusions, the NIH3T3 cell model is inadequate to study the gene expression pattern induced by EWS-ETS proteins in Ewing's sarcoma. Thus, data derived from the NIH3T3 model system needs to be appropriately validated before they can be accepted as relevant to the human disease.