Implementation of Electronic Medical Record Template Improves Screening for Complications in Children with Type 1 Diabetes Mellitus.

OBJECTIVE: Health professionals and patients should follow comprehensive screening guidelines to recognize early signs of long-term complications for insulin-dependent type 1 diabetes mellitus (T1DM). The aim of this study is to demonstrate that utilization of electronic medical record (EMR) templates for diabetes management improves adherence to International Society for Pediatric and Adolescent Diabetes (ISPAD) screening guidelines. METHODS: All patients with T1DM who were seen in the outpatient pediatric endocrine clinic (age 0-22 years old) at an urban community-based community hospital during the 2014 calendar year were enrolled in the study (n=49). A retrospective chart review was performed and audited against ISPAD guidelines. An EMR template and order set was then created based on ISPAD screening guidelines with the aim of improving compliance. The templates were implemented in 2015 (initial phase) and 2016 (maintenance phase) and these data were compared to baseline data. A chi-squared test was performed to analyze the differences between the data using SAS version 9.4 (SAS Institute, Inc). A p-value less than 0.05 was considered significant. RESULTS: Significant improvements (p< 0.05) in screening guideline adherence from baseline to maintenance phase data were found for annual retinopathy (0% to 45%) and neuropathic foot (0% to 64%) exams, screening for microalbuminuria (49% to 79%), celiac disease (6% to 81%), lipids (63% to 86%), and basic metabolic panel (69% to 88%). Of note, thyroid function testing was also increased, but was not statistically significant between the years. CONCLUSION: The utilization of EMR templates and order sets for T1DM are valuable tools to aid medical providers in adhering to ISPAD screening guideline.

Colloidal Silver Ingestion Associated with Leukocytoclastic Vasculitis in an Adolescent Female.

BACKGROUND Leukocytoclastic vasculitis is a disease of the small vessels and is uncommon in children. In this case report, we present an adolescent case of leukocytoclastic vasculitis associated with the ingestion of colloidal silver, a naturopathic drug. This report highlights the rarity of the patient's presentation and inducing agent. CASE REPORT A 19-year-old female presented in the Emergency Department with severe rash on the face, and neck, and then continued to spread in a craniocaudal fashion during the day of presentation to involve trunk, back, upper and lower extremities. There was no recent travel, no pets and a negative family history for rheumatologic or autoimmune diseases. Her home medications included colloidal silver for "internal cleansing" for 4 weeks prior to Emergency Department presentation. Once the clinicians were aware of the continued ingestion of colloidal silver, the patient was advised to discontinue the drug. The patient was started on methylprednisolone with preliminary diagnosis of vasculitis, as well as concurrent therapy with colchicine. The rash was noted to be receding from the face within 24 hours. Over a hospital course of 5 days, the patient's rash and pruritus continued to slowly improve. CONCLUSIONS The ingestion of a naturopathic drug, colloidal silver, caused vast leukocytoclastic vasculitis in our patient warranting hospitalization due to the extent of the disease. The symptoms resolved after discontinuation of colloidal silver ingestion. Due to unknown safe ingestion concentrations and potential side effects, use of colloidal silver should be discouraged.

Diagnosis of Tuberculosis in an Asymptomatic Child, Sibling, and Symptomatic Pregnant Mother in New York City by Tuberculin Skin Testing and the Importance of Screening High-Risk Urban Populations for Tuberculosis.

BACKGROUND In 2017, in New York City (NYC), 86% of the cases of tuberculosis (TB) occurred in patients who were born outside the United States (US). This case report illustrates the importance of the use of the tuberculin skin test (TST), and other tests for TB infection (TTBI), in screening high-risk groups, the challenges of diagnosing TB in young children, and highlights the importance of preventing a delay in the diagnosis of TB in family members. CASE REPORT Following a routine TST in an asymptomatic 10-year-old girl, a diagnosis of TB was made, which was confirmed on chest X-ray (CXR) and by the presence of acid-fast bacilli (AFB) in the sputum. Her family had emigrated from China to NYC ten years previously. All the family was screened using the TST, which was positive in her 2-year-old sister and her 37-year-old pregnant mother, and pulmonary TB was confirmed on CXR and by AFBs in the sputum. All three family members and the newborn baby were treated according to current guidelines, with a good clinical outcome. CONCLUSIONS This case report raises awareness about the lack of symptoms in childhood TB and the importance of screening high-risk patients in an urban immigrant population. In children under 5 years of age, a diagnosis of TB can indicate a sentinel event, suggesting a potential undiagnosed or untreated source case, which is usually an adult family member. This report highlights the challenges of diagnosing TB in children, who may be asymptomatic with negative laboratory findings.

Video didactic at the point of care impacts hand hygiene compliance in the neonatal intensive care unit (NICU).

OBJECTIVE: To increase the hand-washing (HW) duration of staff and visitors in the NICU to a minimum of 20 seconds as recommended by the CDC. METHODS: Intervention included video didactic triggered by motion sensor to play above wash basin. Video enacted Centers for Disease Control and Prevention (CDC) HW technique in real time and displayed timer of 20 seconds. HW was reviewed from surveillance video. Swabs of hands plated and observed for qualitative growth (QG) of bacterial colonies. RESULTS: In visitors, the mean HW duration at baseline was 16.3 seconds and increased to 23.4 seconds at the 2-week interval (p = .003) and 22.9 seconds at the 9-month interval (p < .0005). In staff, the mean HW duration at baseline was 18.4 seconds and increased to 29.0 seconds at 2-week interval (p = .001) and 25.7 seconds at the 9-month interval (p < .0005). In visitors, HW compliance at baseline was 33% and increased to 52% at the 2-week interval (p = .076) and 69% at the 9-month interval (p = .001). In staff, HW compliance at baseline was 42% and increased to 64% at the 2-week interval (p = .025) and 72% at the 9-month interval (p = .001). Increasing HW was significantly associated with linear decrease in bacterial QG. CONCLUSIONS: The intervention significantly increased mean HW time, compliance with a 20-econd wash time and decreased bacterial QG of hands and these results were sustained over a 9-month period.

Effectiveness of Early Antiviral Therapy in Disseminated Neonatal Herpes Simplex Virus 2 (HSV-2) with Fulminant Hepatic Failure.

BACKGROUND Liver failure in the neonatal population is a life-threatening complication and has a wide array of etiologies, including infectious, immune-mediated, metabolic, or drug-induced. Although neonatal herpes simplex virus (HSV) hepatitis only accounts for 1% of all acute liver failures, it has an extremely aggressive clinical course that carries a mortality rate of 85%. CASE REPORT We report a rare case of disseminated neonatal HSV-2 with late presentation associated with fulminant liver failure. The patient recovered without obvious neurologic deficits or need for liver transplant. CONCLUSIONS This case study emphasizes and promotes awareness of early recognition and appropriate clinical management of neonatal HSV infection, and its positive outcome.

Neurological Complications following Blood Transfusions in Sickle Cell Anemia.

In Sickle Cell Anemia (SCA) patient blood transfusions are an important part of treatment for stroke and its prevention. However, blood transfusions can also lead to complications such as Reversible Posterior Leukoencephalopathy Syndrome (RPLS). This brief report highlights two cases of SCA who developed such neurological complications after a blood transfusion. RLPS should be considered as the cause of neurologic finding in patients with SCA and hypertension following a blood transfusion.

Metastatic Colon Cancer in an 18-Year-Old without Predisposing Factors.

While colorectal carcinoma is a common gastrointestinal cancer in adults, it is rare in pediatrics with an incidence of 1 : 1,000,000 and represents a fraction of neoplasms encountered in children. Malignant neoplasms represent a major cause of mortality in the pediatric age group. While presenting with weight loss, iron deficiency, rectal bleeding, abdominal pain, and change in bowel habits, or symptoms similar to acute appendicitis, the working diagnosis may be considered to be anorexia. This case illustrates the importance of considering colon cancer among other disease entities as a cause of unintentional weight loss in adolescents. While this is a rare occurrence in the pediatric population, significant unintentional weight loss with altered bowel habits should prompt a search for underlying malignancy-even in the absence of a positive family history or predisposing cancer syndromes.

Physician Transition of Care: Benefits of I-PASS and an Electronic Handoff System in a Community Pediatric Residency Program.

BACKGROUND: Miscommunication is a leading cause of adverse events in hospitals. Optimizing the handoff process improves communication and patient safety. We sought to assess how the components of I-PASS (a mnemonic for illness severity, patient summary, action list, situational awareness with contingency planning, and synthesis by the receiver), a standardized handoff bundle, improved the quality of handoffs in a pediatric residency program based in a community hospital. METHODS: Pediatric residents in a university-affiliated community teaching hospital were observed on the pediatric inpatient floor and in the newborn nursery. One hundred resident handoffs per setting were analyzed in 3 phases, with a total of 600 handoffs assessed. Phase 1 comprised preintervention handoffs before I-PASS; phase 2, initiating I-PASS mnemonic and educational session; and phase 3, implementing a handoff tool, electronic physician handoff (EPH), into the electronic medical record. One attending physician at each setting assessed the handoff process using an 11-item survey. A resident satisfaction survey assessed the resident's experience after phase 3. RESULTS: Comparing phase 1 with phase 2, there was improved situational awareness with contingency planning (nursery: 12% to 83%, P = .001; floor: 21% to 84%, P = .001). Incidence of tangential conversation decreased in both settings (nursery: 100% to 23%, P = .001; floor: 84% to 11%, P = .001). Comparing phase 2 with phase 3, there was improvement in identification of illness severity (nursery: 62% to 99%, P = .001; floor: 41% to 64%, P = .001) and fewer omissions of important information (nursery: 14% to 0%, P = .001; floor: 33% to 17%, P = .007). A total of 93% of residents found the new EPH system to be beneficial. CONCLUSIONS: Specific components of a standardized handoff system, including a mnemonic, an educational intervention, and an EPH, improved the clarity and organization of key information in handoff.

Increasing maternal body mass index during pregnancy increases neonatal intensive care unit admission in near and full-term infants.

BACKGROUND: Obesity is becoming an increasingly commonplace health problem. Obesity during pregnancy is important because the condition adversely affects not only the mother, but also the developing fetus and the newborn. OBJECTIVE: The primary objective of this study was to evaluate the association between maternal body mass index (mBMI) at the time of delivery and neonatal intensive care unit (NICU) admission of offspring and to analyze the role of possible confounding variables that are often associated with obesity. Comorbidities, such as gestational diabetes mellitus (DM), hypertension (HT) and/or pre-eclampsia (PEC), are more common in more obese mothers, as is a higher association of obesity among non-Caucasian patients. METHODS: Using a retrospective cohort design, 1736 mothers and their singleton live-born at ≥35 weeks' gestation were analyzed for mBMI, maternal conditions of DM, HT and/or PEC, and whether NICU care was required and the reason for NICU admission. RESULTS: NICU admission rate was significantly associated with maternal obesity. In comparing women with mBMI < 30 versus mBMI ≥ 30, OR was 1.39 (p = 0.045); OR increased to 1.76 (p = 0.006) in comparing patients with mBMI ≥ 35. mBMI was significantly associated with an increased rate of maternal DM, HT and PEC (p < 0.05 each); however, NICU admission rate was not correlated with DM, HT or PEC. The relationship between NICU admission and mBMI was significant in Caucasian mothers versus a borderline significance in African-American mothers (p = 0.035 versus p = 0.05). After controlling for neonatal hypoglycemia (NH) as the reason for admission to the NICU, no mBMI-NICU association persisted. The rate of infants with NH increased in higher mBMI groups, independent of maternal DM diagnosis. CONCLUSION: This study demonstrated a significant association between higher mBMI groups and NICU admissions independent of diagnosis of maternal comorbidities. However, accounting for NH eliminating this association suggests a pre-clinical diabetic pathology in obese women that affects newborn outcome. Despite increased percentage of nonwhite mothers in higher mBMI groups, African-American race does not seem to be a significant contributing factor in the increased rate of NICU admission in our population.