The Florida Pediatrician, Fall 2016

Page 1

The Peer Reviewed Journal of the Florida Chapter of the AAP

Volume 35, Issue 4

Fall 2016




Contents Highlights of Guidelines From the Recent Past: 6 Questions and Answers John W. Waidner MD


The 3rd Annual Pediatric Medical Student Research Forum

18 First Annual Pediatric Resident Advocacy Forum

22 The 2016 FCAAP Brain Bowl

The Florida Pediatrician is the peer reviewed journal of the Florida Chapter of the American Academy of Pediatrics, published by the FCAAP Editorial Board for FCAAP members.

Florida Chapter of the American Academy of Pediatrics, Inc. 75 N. Woodward Ave. #87786, Tallahassee, FL 32313 850-224-3939 2


Editor’s Note There was an election... and it was civilized. Our chapter leadership changed at the Annual FCAAP Annual meeting. I want to congratulate Dr. Madeline Joseph who took over as President. I am especially proud of Madeline who was my senior Resident of the very first month of my first year as an attending on the Floor. And yes – inpatient pediatric was practiced by us before there were specialists. I recognized at that time that Madeline was a star and will have a successful career and that she did. Thanks to my dear friend Dr. Tommy Schechtman for completing a successful tenure as President for two years and will now serve as the Immediate Past-President. Dr. Paul Robinson will take over as Vice President and Dr. Toni RichardsRowley will be the new Treasurer. Dr. Eugene Hershorin will continue to share his skills as the Secretary of the Chapter. We also have several new board members and a few returning board members. I want to congratulate all who volunteered to serve whether or not they were elected and hope that those not elected will continue to stay active with the Chapter. The national AAP election starts soon. Please vote. We had another very successful Annual meeting with participation by medical students, thanks to Dr. Rivkees and greater participation by residents thanks to the program directors. We hope that this trends continues. Zika continues to dominate medical news. Zika Congenital Syndrome (ZiCS) is now much better described and the knowledgebase continues to increase exponentially. Florida has done well in responding to Zika outbreak in Miami. However some are concerned about how well are the State and pediatric providers ready to meet the challenge of ZiCS. I believe we have to do more preparations to be ready at the major pediatric centers around the State to be prepared. Your chapter is working with American Academy of Pediatrics to address this gap. Your chapter has also reached out to the Florida department of health to get better organized to receive and manage Zika exposed and ZiCS babies. Stay tuned. We “survived” hurricane Matthew. It could have been much worse. We are looking at what additional resources can your chapter and AAP provide to pediatricians to better deal with the aftermath of a disaster, especially hurricanes. Your chapter leadership continues to work with the State to remove barriers for children to more easily access care and we hope to see many changes in the near future. The “Physician Gag Law” appeal was heard by the full 11th Circuit Court of appeals in Atlanta and we await their decision. For now you can continue to ask about firearms and provide anticipatory safety guidance to your families and patients so that we can avoid an unfortunate firearm related morbidity and mortality. Regards,

Mobeen H. Rathore, MD, FAAP FALL 2016


Editorial Board Mobeen H. Rathore, MD, CPE, FAAP, FPIDs, FSHEA, FIDSA, FACPE Editor, The Florida Pediatrician Professor and Director University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES) Chief, Infectious Diseases and Immunology, Wolfson Children’s Hospital Jacksonville Jacksonville, FL

Roger L. Berkow, MD Chair, Department of Medicine Pediatric Hematology/Oncology Nemours Children’s Clinic, Pensacola Pensacola, FL

Lisa Gwynn, DO, MBA, FAAP, CPE Assistant Professor, Department of Pediatrics Medical Director, Pediatric Mobile Clinic University of Miami Miller School of Medicine Director, Innovation and Community Engagement Mailman Center for Child Development Miami, FL

Gregory A. Hale, MD, CPE, FAAP, FACHE, CTI, CHCQM, CPHQ, CPPS Associate Professor of Oncology and Pediatrics Johns Hopkins University Pediatric Cancer and Blood Disorders Institute All Children’s Hospital St. Petersburg, FL

Nizar F. Maraqa, MD, FPIDS Associate Professor & Fellowship Program Director Pediatric Infectious Diseases & Immunology University of Florida College of Medicine, Jacksonville Jacksonville, FL



Editorial Board Molly McGetrick, BA MD Resident, PGY-2 University of Florida Gainesville, FL

Michael J Muszynski, MD Orlando Regional Campus Dean Associate Dean for Clinical Research Professor of Clinical Sciences The Florida State University College of Medicine Orlando, FL

Juan Felipe Rico, MD Assistant Professor, University of South Florida College of Medicine Department of Pediatrics Tampa, FL

D. Paul Robinson, M.D. Associate Clinical Professor, Florida State University School of Medicine Tallahassee, FL

Interested in joining the FCAAP Editorial Committee or submitting an article for a future publication? Contact the Editorial Committee at for more information!

FALL 2016


Highlights of Guidelines From the Recent Past: Questions and Answers John W. Waidner MD

Pediatric Emergency Medicine Fast Track Physician, Wolfson Children’s Hospital Pediatric Medical Director, Centene Corporation Volunteer Faculty, St. Vincent’s Family Medicine Residency Program Assistant Clinical Professor, Florida State University College of Medicine Assistant Clinical Professor, Nova Southeastern University College of Medicine

QUESTION #1: A 7mo old white male presents to the Emergency Department (ED) with 48 hours of progressively increasing nasal congestion and cough. His mother is concerned that he is breathing a little faster and heavier than usual and he is feeding less than usual but still having wet diapers. He has no significant past medical history. In the ED he is afebrile, HR 110 beats/ minute, RR 48 breaths/minute and his SaO2 is 92% on room air. On physical examination he is alert and will smile but has marked nasal congestion and bilateral expiratory wheezing. He is fairly comfortable other than mild intercostal retractions. His work of breathing improves after nasal saline and suctioning. A trial of albuterol via nebulizer has no impact on his wheezing. Nasal mucous is sent for Respiratory Syncytial Virus (RSV) testing and is positive. His chest radiograph (CXR) shows hyperinflation, and haziness in the Right Lower Lobe interpreted as “atlectasis vs inflitrate” by radiology. Based on parental concern, borderline feeds and increased work of breathing he is admitted for observation. 6


Of the following the most essential factor to allow a diagnosis of Bronchiolitis in this child is: A) Chest Radiograph B) History and physical examination findings C) Respiratory syncytial Virus testing D) Response to albuterol The answer to this question is B. According to the latest Am erican Academy of Pediatrics (AAP) Guideline on Bronchiolitis, this infant, who clinically has an illness quite typical for bronchiolitis, does not need viral testing or a CXR to assist in the diagnosis. He also does not need a trial of albuterol for the treatment of wheezing. We will explore each of these points a bit more below. • The American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management and Prevention of Bronchiolitis was published in November 2014 in Pediatrics. It replaced an earlier version of the guideline from 2006. It applies to children from 1 to 23 months of age and specifically excludes children in certain groups such as children with immunodeficiency, Human Immunodeficiency Virus, solid organ or bone marrow transplantation, children with recurrent wheezing/Bronchopulmonary Dysplasia/ Cystic Fibrosis, children with neuromuscular disorders and children with hemodynamically significant congenital heart disease. • The Guideline reinforces some basic principles including: 1) The most common etiology of bronchiolitis (about 75%) is respiratory syncytial virus (RSV) Other viruses that cause bronchiolitis include human rhinovirus, influenza, parainfluenza, adenovirus, coronavirus, and human metapneumovirus. 3) RSV is very common as ninety percent of children are infected with RSV in the first 2 years of life, and up to 40% will experience lower respiratory tract infection during the initial infection. 4) The highest incidence of infection occurs between December and March in North America; however, regional variations occur. Florida’s season starts earlier and lasts longer than the rest of the US, with increased levels of RSV detection starting in August and lasting until May, with the possibility of RSV year around. • The first key action statement of the guideline has several points but two of the main points are: 1) Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. (Evidence Quality: B; Recommendation Strength: Strong Recommendation). and 2) When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely (Evidence Quality: B; Recommendation Strength: Moderate Recommendation). Large studies of infants hospitalized for bronchiolitis have consistently found that 60% to 75% have positive test results for RSV , and have noted coinfections with other viruses in up to one-third of infants, These results do not change management. One exception to this recommendation is in the event an infant receiving monthly prophylaxis is hospitalized with bronchiolitis, testing should be performed to determine if RSV is the etiologic agent. RSV testing shows this to be the infecting virus, palivizumab should be discontinued as a 2nd RSV infection the same year is very unlikely. In regards to chest x-rays, although many infants with bronchiolitis have abnormalities on chest radiography (mainly atelectasis), data are insufficient to demonstrate that chest radiography correlates well with disease severity. One randomized trial, suggests that children with suspected lower respiratory tract infection that had radiography performed were more likely to receive antibiotics with no difference in outcomes. For these reasons, initial radiography should be reserved for cases in which respiratory effort is severe enough to warrant ICU admission or where signs of an airway complication (such as pneumothorax) are present. • The Second key action statement is a departure from the prior practice guideline. It states: Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation). Most randomized controlled trials have failed to demonstrate a consistent benefit from α- or β-adrenergic agents. Although transient improvements in clinical scores have been observed with albuterol, it’s use does not affect disease resolution, need for hospitalization, or length of stay. In the previous version of this guideline, a trial of β-agonists was included as an option. That is no longer the case. There is some limited data on the nebulized epinephrine and nebulized hypertonic saline. The data on epinephrine is mainly ED limited data on the prevention of hospitalization and the hypertonic saline data on inpatients with prolonged stays. Neither is recommended for routine use. FALL 2016


• There are many additional recommendations in the new guideline but space limits our ability to cover them all here. One additional point, however, is worth mentioning. Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis (Evidence Quality: C, Recommendation Strength: Weak Recommendation [based on lower level evidence]. In this authors clinical experience the use of continuous pulse oximetry is one of the biggest contributors to prolonged hospital stays for infants with bronchiolitis. A few points to back this up: 1) Transient desaturation is normal: In 1 study of 64 healthy infants between 2 weeks and 6 months of age, 60% of infants exhibited a transient oxygen desaturation below 90%, to values as low as 83%. 2) A retrospective study of the role of continuous measurement of oxygenation in infants hospitalized with bronchiolitis found that 1 in 4 patients incur unnecessarily prolonged hospitalization as a result of a perceived need for oxygen.

QUESTION #2: The mother of an 8 year old girl calls in a bit of a panic that the school just notified her that the child has head lice. Of the following , the most appropriate management of this child is: A) She should be sent home, and not allowed to return until there are no live lice on exam. B) She should be sent home, and not allowed to return until there are no live lice AND no visible nits C) There is no reason to exclude her from school, but avoiding direct head to head contact with other children is advised. The answer to this question, according to the AAP Clinical Report: Head Lice, published in Pediatrics in May 2015 is choice C. There is no reason to exclude her from school, but trying to avoid direct head to head contact with other children is advised. We will explore some of the guideline highlights below. • The guideline covers some basics including: 1) Head lice are a very common problem and concerning (to parents and schools); 2) Head lice are a very expensive problem, with latest estimates of direct and indirect costs approaching 1 billion dollars annually; 3) Head lice are not a health hazard or a sign of poor hygiene and are not responsible for the spread of any disease; and 4) Despite this knowledge, there is significant stigma resulting from head lice infestations in many developed countries, resulting in children being ostracized from their schools, friends, and other social events. • Other “fun facts” about head lice included in the guideline are: 1) Lice do not hop or jump; they can only crawl, but static electricity from hair combing has been reported to launch a louse up to 1 meter!; 2) Pets do not play a role in the transmission of human lice; 3) In most cases, transmission occurs by direct, head to head contact; and 4) Indirect spread through contact with personal belongings of an infested individual (combs, brushes, hats) is much less likely to occur. Lice are usually dead by the time they are seen. In 1 study, live lice were found on only 4% of pillowcases used by infested volunteers. • Points in regards to diagnosis include: 1) Identification of eggs (nits), nymphs, or adult lice with the naked eye establishes the diagnosis; 2) It is important not to confuse eggs or nits, which are firmly affixed to the hair shaft, with dandruff, hair casts, or other hair debris, which are not; 3) Tiny eggs may be easier to spot at the nape of the neck or behind the ears, within 1 cm of the scalp; and 4) In general, eggs found more than 1cm from the scalp are unlikely to be viable, although some researchers in warmer climates have found viable eggs farther from the scalp. • Highlights of treatment include: 1) Unless resistance to these products has been proven in the community, 1% permethrin or pyrethrins are a reasonable first choice for primary treatment of active infestations if pediculicide therapy is required; 2) Because current products are not completely ovicidal, applying the product at least twice, at proper intervals, is indicated if permethrin or pyrethrin products are used or if live lice are seen after prescription therapy per manufacturer’s guidelines; 3) Benzyl alcohol 5% can be used for children older than 6 months, or malathion 0.5% can be used for children 2 years or older in areas where resistance to permethrin or pyrethrins has been demonstrated; 4) Spinosad and topical ivermectin are newer preparations that might prove helpful in difficult cases, but the cost of these preparations should be taken into account by the prescriber; and 5) If the patient is too young, or if parents do not wish to use a pediculicide, consider the manual removal of lice/nits by methods such as “wet-combing” or an occlusive method (such as petroleum jelly). The guideline also reviews off-label and other alternative treatment options. The reader is referred to the guideline for further information on these as they exceed the scope of this review. 8


• Environmental control measures highlighted in the review include: 1) All household members should be checked for head lice, and those with live lice or nits within 1 cm of the scalp should be treated; 2) It is prudent to treat family members who share a bed with the person with infestation; 3) Only items that have been in contact with the head of the person with infestation in the 24 to 48 hours before treatment should be considered for cleaning, given the fact that louse survival off the scalp beyond 48 hours is extremely unlikely; 4) Washing, soaking, or drying items at temperatures greater than 130°F will kill stray lice or nits; 5) It is unlikely that there is a significant risk of transmission in swimming pools; and 6) Although it is rarely necessary, items that cannot be washed can be bagged in plastic for 2 weeks, a time when any nits that may have survived would have hatched and nymphs would die without a source for feeding. • Finally, the guidance on school issues (related to our initial question above) are as follows: 1) No healthy child should be excluded from school or allowed to miss school time because of head lice or nits; 2) Pediatricians may educate school communities that no-nit policies for return to school should be abandoned; 3) Head lice screening programs have not been proven to have a significant effect over time on the incidence of head lice in the school setting and are not cost-effective; and 4) Parent education programs may be helpful in the management of head lice in the school setting. In this author’s experience, the policy recommendations of this guideline deviate greatly from the widespread exclusion policies of many school systems. Significant community pediatrician “buy in” and education/partnering with school systems will be required.

QUESTION #3: A 3 month old infant was well and in his usual state of good health until 30 minutes after a feeding when he gasped and choked, according to his mother, with a pause in breathing and a pale appearance around his mouth. He seemed to arch his back a bit during this “spell”. His mother panicked, gave him one or two rescue breaths and called 911. On arrival to the emergency department he is well appearing. The most appropriate term for this event would be: A) Apparent Life Threatening Event) (ALTE) B) Brief Resolved Unexplained Event (BRUE) C) Near Miss SIDS D) Unexplained Paroxysmal Event (UPE) The answer is B, Brief Resolved Unexplained Event (BRUE). In May 2016 the AAP published new guidance on this subject in Pediatrics. We will explore some of the highlights from the executive summary below. • The major change in this guideline is the promotion of a new term to replace the long used, Apparent Life Threatening Event (ALTE), with the newer term Brief Resolved Unexplained Event (BRUE). In addition the guideline provides guidance on risk stratification and evaluation. It is recommended that the term BRUE be applied when an infant presents with a history of a sudden, brief and now resolved episode that involves at least one of the following: 1) cyanosis or pallor, 2) absent, decreased or irregular breathing, 3) marked change in tone (either increased or decreased), and 4) altered level of responsiveness. In addition, providers should only use the term BRUE when, after a thorough history and physical examination, no other explanation for the qualifying event is found. • Once an event has been classified as a BRUE, the guideline provides guidance on stratifying these infants into low and high risk groups. Low risk classification criteria include: 1) Age >60 days, 2) gestational age >32 weeks and post-conceptual age >45 weeks, 3) occurrence of only one BRUE (no prior BRUE’s ever and no clusters of events currently), 4) the duration of the BRUE was less than 1 minute, 5) there was no Cardiopulmonary Resuscitation (CPR) by trained medical professionals, and 6) there are no concerning historical features or physical examination findings. • According to the guideline, data is limited on such events in high risk infants and no specific recommendations about evaluation are made for those infants. Evaluation and work up on high risk infant(those who do not meet the low risk criteria outlined above) should be on a case by case basis.

FALL 2016


• Specific recommendations about evaluation of low risk infants are made and are broken down on a spectrum into 4 categories: “Should”, “May”, “Need Not” and “Should Not” • Clinicians SHOULD: • Educated caregivers about BRUE’s and engage in shared decision making to guide evaluation, disposition and follow up. • Offer the caregiver resources for CPR training • Perform a thorough history and physical exam, including a thorough social history with attention towards the possibility of abuse. • Clinicians MAY: • Obtain Pertussis testing and 12 Lead Electroencephalogram (EEG) • Briefly monitor patients with continuous pulse oximetry and serial observations • Clinicians NEED NOT: • Obtain White Blood Cell count, blood culture, Cerebrospinal fluid analysis/culture, electrolytes, ammonia, blood gas, urine organic acids/plasma amino acids, acylcarnitine CXR, Echocardiography, EEG or studies for gastroesophageal reflux • Initiate home cardio-respiratory monitoring • Prescribe acid suppression therapy or antiepileptic medications • Clinicians SHOULD NOT: • Obtain viral respiratory testing, urinalysis, blood glucose, serum bicarb, serum lactic acid, lab testing for anemia, neuroimaging, or sleep studies/polysomnography (PSG). • Admit the patient to the hospital solely for cardiorespiratory monitoring. • A detailed discussion of the guideline is too broad for this review but the guideline does contain an extensive and well referenced discussion of each of the bulleted points above. The take home message is one that is core to almost all medicine. The answer is usually found in a thorough history and physical and a targeted evaluation, based on the history and physical examination, is superior to a broad “shotgun” approach both in terms of clinical care and cost containment.

REFERENCES 1. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis Ralston et al. PEDIATRICS Volume 134, Number 5, November 2014:e1479 2. Clinical Report: Head Lice. Devore et al. PEDIATRICS Volume 135, number 5, May 2015 3. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Tieder et al. PEDIATRICS Volume 137, number 5, May 2016:e20160590



The 3rd Annual Pediatric Medical Student Research Forum The Third Annual Pediatric Medical Student Research Forum was hosted during The Future of Pediatric Practice 2016 over Labor Day weekend at Disney’s Grand Floridian Resort and Spa. The 2016 Forum was sponsored by the University of Florida, Boston Children’s Hospital, the National Institute of Child Health and Human Development (“NICHD”), and the Florida Chapter of the American Academy of Pediatrics. The Forum, which is open to medical students across the United States, hosted more than 100 students and was led by Drs. Scott Rivkees and Maria Kelly of the University of Florida, Dr. Mary Lodish of NICHD, and Dr. Debra Weiner of Boston Children’s Hospital. In addition to poster and oral presentations from some of the top pediatric medical students in the United States, the Forum also included a career discussion and a presentation by Dr. Duane Mitchell on Novel Approaches for Brain Tumor Immunotherapy in Children. Throughout the Forum, judges observed the oral and poster presentations of each participating student. At the end of the Forum, the top three oral presentations and the top three poster presentations were selected. Congratulations to everyone who presented during the Forum and congratulations to the winners! The abstracts of the winning student presentations are published here.





Visualizing Dystrophic and Rescued Muscle in a New Light

Stephen Chrzanowski

College of Medicine, University of Florida, Gainesville

1st Place Oral

Pediatric Health Risk Assessment of Air Pollution from Seven Major California Airports

Subha Mohan

David Geffen School of Medicine, University of California, Los Angeles

2nd Place Oral

Utilizing the Benefits of Biofilms: Prevention of Necrotizing Enterocolitis Using a Novel Probiotic Delivery System

Sarah Gartner

The Ohio State University College of Medicine

3rd Place Oral – Tie

Sex Differences in miRNA Expression after Isoflurane Anesthesia: A Pilot Study

Brianne Wiemann

The Ohio State University College of Medicine

3rd Place Oral – Tie

Chimeric Antigen Receptor T-Cell Therapy of Differentiated Thyroid Cancer

Kartik Motwani

College of Medicine, University of Florida, Gainesville

1st Place Poster

The Effect of Maternal Smoking on CFTR Function of the Neonate

Lydia McCormick

Department of Medicine, University of Alabama at Birmingham

2nd Place Poster

Treatment Of Pediatric Abdominal Angiosarcoma With Cytoreductive Surgery And Hyperthermic Intraperitoneal Chemotherapy

Lindsey Winer

University of Miami Miller School of Medicinet

3rd Place Poster

FALL 2016


ORAL PRESENTATION – 1ST PLACE VISUALIZING DYSTROPHIC AND RESCUED MUSCLE IN A NEW LIGHT Presenting Author: Stephen Chrzanowski Chrzanowski SM1, Vohra R1, Lee-McMullen BA1, Batra A2, Forbes SC2, Vandenborne K2, Barton E3, Walter GA1 1 Department of Physiology and Functional Genomics, College of Medicine, University of Florida, Gainesville, FL, 2 Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, 3 Applied Physiology & Kinesiology, College of Health and Human Performance, University of Florida, Gainesville, FL Background: The muscular dystrophies are a heterogeneous spectrum of neuromuscular disorders that lead to rapid wasting of muscle and premature mortality. Duchenne muscular dystrophy is the most common and one of the most devastating forms of muscular dystrophy, leading to early loss of ambulation and death by the 3rd decade. Current means to measure therapeutic efficacy for these diseases remain inadequate, limited to invasive muscle biopsies and functional testing. Muscle biopsies are inadequate because they are invasive, provide a limited sampling of this very heterogeneous disease, and further damage already degenerative tissue. Functional testing possesses inherent variables that remain difficult to control, such as subject motivation and compliance. An ideal methodology of assessing therapeutic treatment must be: highly sensitive and specific to biologic changes, inexpensive, non-invasive, minimally exposing to harmful radiation, and comfortable for patients. Near infrared (NIR) optical imaging (OI) and magnetic resonance imaging (MRI) may offer potential as non-invasive modalities to quantitatively assess muscle pathology in acutely injured and diseased muscle. Using an FDA approved near infrared fluorophore, we tested whether healthy, damaged, dystrophic, and rescued muscle could be imaged and differentiated with NIR-OI, with confirmation provided by MRI, histological, and spectrophotometric measures. Hypothesis: It is anticipated that NIR-OI will be able to detect muscle pathology as a result of natural disease progression, exacerbation of pathology following an eccentric muscle damaging exercise protocol, and mitigation of disease following a therapeutic intervention. Methods: Age matched 6-10 week old control, mdx, and Sgcg -/- mice were cross sectionally compared by NIR-OI, MRI, histology, and spectrophotometry. Next, data were collected from additional mdx mice that were subjected to downhill treadmill running. Finally, a subset of Sgcg -/- mice received intramuscular injections of AAVs loaded with human γ-sarcoglycan. For both the treadmill exercised and AAV treated cohorts, data were collected before and after the respective interventions. 2D fluorescence images were captured using wavelengths of 745Ex and 820Em nm. For MR, multiple slice spin echo scans were acquired to assess MRI-T2 relaxation. Following imaging, mice were injected with Evan’s blue dye and standard histological techniques and spectrophotometry were performed. Results: Radiant efficiency was elevated in both mdx (5.9 fold) and Sgcg-/- (8.5 fold) mouse models compared to unaffected control mice. Similarly, MRI-T2 values were elevated in mdx (0.15 fold) and Sgcg-/- (0.22 fold) mice as compared to unaffected control mice. The downhill eccentric loading exercising significantly induced damage to the fore- and hindlimb muscles by both MRI-T2 (0.12 fold) and NIR-OI (0.89 fold). Following 6 weeks of AAV treatment, gsg -/- mice were observed to have decreased MRI-T2 (-0.08 fold) and radiant efficiency (- 0.58 fold) as compared to pre-intervention and non-treated counterparts. 12


Conclusions: NIR-OI can be used to image muscle damage in dystrophic muscle and detect exacerbated muscle damage, and regression of disease burden following therapy. This work supports NIR-OI as a feasible, cost effective, non-invasive, longitudinal means to quantify muscle health.

ORAL PRESENTATION – 2ND PLACE PEDIATRIC HEALTH RISK ASSESSMENT OF AIR POLLUTION FROM SEVEN MAJOR CALIFORNIA AIRPORTS Presenting Author: Subha Mohan Subha Mohan1, Ronald C. Henry PhD2, Shahram Yazdani MD3 1David Geffen School of Medicine, University of California, Los Angeles (UCLA), 2Department of Civil and Environmental Engineering, University of Southern California (USC), 3Department of Pediatrics, Mattel Children’s Hospital and David Geffen School of Medicine, University of California, Los Angeles (UCLA). Introduction: Airports are a significant and increasing source of air pollutants such as polycyclic aromatic hydrocarbons, black carbon, NOx, and ultrafine particles that have been linked to various respiratory, genotoxic, immunologic, and neurologic problems in children.1-4 Children are particularly vulnerable to air pollution because of their increased growth, activity, and oxygen consumption relative to adults.1 Additionally, evidence supports the notion that outdoor air pollutants translate into indoor pollution exposure.5 The goal of this project was to examine the size, demographics, and level of airportrelated air pollution exposure of the pediatric population attending school within the 10-km radius of 7 major California airports located in highly populated areas: Los Angeles International Airport (LAX), San Francisco International Airport (SFO), San Jose International Airport (SJC), Burbank Bob Hope Airport (BUR), Long Beach Airport (LGB), Van Nuys Airport (VNY), and Santa Monica Airport (SMO). Hypothesis: Children attending schools around busy airports experience a gradient of increased risk of exposure to airportrelated air pollution. This gradient depends on topographic and meteorological factors including distance and wind direction. Children of low socioeconomic status (SES) face disproportionately higher risk of such exposure. Methods: The California Department of Education (CDE) database was utilized to identify all schools located in each zip code within 10 km of each airport, as well as each school’s 2015-2016 enrollment data. Schools whose data was not available online were contacted individually. The CDE website also contained the socioeconomically disadvantaged enrollment of each public school (both charter and non-charter). Maximum pollution exposure (MPE) time was calculated for each school’s geographic coordinates using Non-Parametric Trajectory Analysis (NTA) algorithms, which used minute-by-minute wind data to construct local back-trajectories to quantify the time each school spent downwind of the airport.6,7 These algorithms were used on 10-15 years of data collected around each airport during the school year (September through May), from 5AM12AM daily. Results: Enrollment data for 745,579 students was available from 1396 of the 1427 total schools (97.83%) located within the 10-km radius of the 7 airports. Maximum pollution exposure (MPE) time (% time spent downwind of the airport) was calculated for each of the 1396 schools. A total of 35,087 students (4.71%) had an MPE>20%, while 3120 (0.42%) had an MPE>50%. Schools surrounding LAX comprised the highest proportion of children exposed to MPE>20% (16,994 students; 2.28%). In public schools, a direct correlation was noted between the % of low SES students and the pollution level. An average increase of 6.1% (range 1.12-13.13%) in % low SES students was found for every 10% increase (0-60%) in MPE in public schools. This trend was most prominent for LAX and VNY. Conclusion: Our findings indicate that thousands of children, and especially those of low SES, are at risk of the negative health effects of airport-related air pollution. Additional pollution-reduction technologies and city planning should be considered to better protect the health of the children attending schools near airports. FALL 2016


ORAL PRESENTATION – 3RD PLACE (TIE) UTILIZING THE BENEFITS OF BIOFILMS: PREVENTION OF NECROTIZING ENTEROCOLITIS USING A NOVEL PROBIOTIC DELIVERY SYSTEM Presenting Author: Sarah Gartner Sarah M. Gartner1, Jacob K. Olson MD2, Chris J. McCulloh MD2, Jason B. Navarro PhD2, Lauren Mashburn-Warren2, Steven D. Goodman PhD2, Gail E. Besner MD2: The Ohio State University College of Medicine1, The Research Institute at Nationwide Children’s Hospital2. Summary: Necrotizing enterocolitis (NEC), a deadly inflammatory intestinal disease affecting premature infants, is characterized by inappropriate microbial colonization causing breakdown of the intestinal mucosal barrier. Probiotics including Lactobacillus reuteri (Lr) have been shown in some studies to protect newborns against NEC, but the results have been variable. In addition, repeated daily administration is required, and several reports of bacteremia from the administered probiotic have been reported. We have developed a novel probiotic delivery system that promotes Lr biofilm formation by allowing Lr to adhere to biocompatible microspheres. This formulation significantly reduces Intestinal mucosal barrier dysfunction in a rat model of experimental NEC. Importantly, these protective effects are produced with administration of just a single dose of the probiotic. Given that NEC is characterized by failure of neonatal intestinal barrier function, these results support the further investigation of our novel probiotic delivery system for the clinical treatment of NEC in the future.

ORAL PRESENTATION – 3RD PLACE (TIE) SEX DIFFERENCES IN MIRNA EXPRESSION AFTER ISOFLURANE ANESTHESIA: A PILOT STUDY Presenting Author: Brianne Wiemann Brianne Wiemann, Medical Student, The Ohio State University College of Medicine; Jason Xia, Medical Student, The Ohio State University College of Medicine; Emmett Whitaker, M.D., F.A.A.P., Clinical Assistant Professor of Anesthesiology, The Ohio State University College of Medicine, Attending Pediatric Anesthesiologist, Nationwide Children’s Hospital Introduction: Recent studies in animal models have raised significant concerns that anesthesia exposure in infancy may lead to permanent neurocognitive deficits later in life. Specifically, increased apoptosis has been observed in immature animals after anesthetic exposure. Thus, it is critical to elucidate the molecular mechanisms that may be responsible for anesthesia-induced neurotoxicity in children. This project incorporates the variable of patient sex in addition to age. Despite the obvious effect of sex on the natural history of multiple diseases, little research has focused on the effect of gender on response to anesthesia. Piglets have emerged as an excellent model for neuroscience research, particularly in the developing brain. We have perfected a piglet model of anesthetic exposure that allows all facets of anesthesia-induced neurotoxicity (AIDN) to be investigated. Thus, this project combines four key factors: 1) novel use of a piglet model to study AIDN; 2) modulation of miRNA expression in response to anesthesia; 3) miRNAs as tools to measure changes in neurochemistry; and 4) the effect of gender on modulation of miRNA expression. Hypothesis: It is hypothesized that clinically-relevant exposure to the general anesthetic isoflurane will affect brain neurochemistry as evidenced by modulation of miRNA expression and that this modulation will favor a more robust neuroinflammatory response in male piglets when compared with female piglets. Methods: Four female and six male healthy piglets, 4-7 days old, were obtained and given 24 hours to acclimate to the environment. All piglets were anesthetized with 2-3% isoflurane in room air (as tolerated) for 3 hours (clinically relevant exposure). Throughout the experimental period, piglets received full physiologic monitoring including temperature, pulse oximetry, invasive and non-invasive blood pressure, electrocardiography, capnography, and end-tidal anesthetic concentration. After exposure, the animals were sacrificed and fresh brain tissue was collected. Untreated animals (5 male, 6 female) served as controls. Brain tissue was homogenized and total RNA extracted. Relative concentrations of miRNAs via a GeneChip Porcine miRNA 4.0 Array (Affymetrix, Santa Clara, CA, USA) were assessed. Results: Hippocampal tissue has been collected and the data is currently being analyzed. Our preliminary genomic and 14


miRNA analysis in male piglets revealed that several miRNAs were significantly downregulated in male piglets following isoflurane exposure (P<0.02). As a whole, this group of miRNAs functions to target genes involved in inflammation, cell proliferation and differentiation, and apoptosis. Of note, these piglets also showed altered expression of inflammatory genes, channel proteins, and cell cycle proteins. Conclusion: It is expected that the results of this pilot study will be similar to our preliminary data. It is reasonable to speculate that there will be a greater neuroinflammatory response in male piglets as evidenced by significant modulation of miRNAs that target genes involved in the inflammatory cascade. This is supported by available data in humans, as it appears that estrogen levels mitigate the inflammatory response in absence of an underlying autoimmune disease. Further, a study that examined the effect of gender on anesthetic neurotoxicity in neonatal rats showed a significant increase in sensitivity to injury in male animals.

POSTER PRESENTATION – 1ST PLACE CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY OF DIFFERENTIATED THYROID CANCER Presenting Author: Kartik Motwani Kartik Motwani1, Nicola R. Weyers2, Christopher C. Wendler3, Lung-Ji Chang4, Scott A. Rivkees3. 1 College of Medicine, University of Florida, Gainesville, FL 32601, 2Universitätsklinikum Aachen, Aachen, 52074, Germany; 3Department of Pediatrics, University of Florida, Gainesville, FL 32601, and 4Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32601, United States. Background: Thyroid cancer presents a pertinent clinical challenge as the most common endocrine cancer, accounting for 3.6% of all new onset cancers and the third most common solid tumor malignancy in children. Papillary (80%) and follicular (15%) thyroid cancer arise from differentiated tissues, and some cases of differentiated thyroid cancer (DTC) are refractory to current treatment modalities including thyroidectomy and 131-iodine radiotherapy. In pediatric populations, the radioactive dose of 131-iodine may cause future complications, discouraging its use. As an additional approach to thyroid cancer treatment, we investigate use of the fourth-generation Chimeric Antigen Receptor T cell (CAR-T) construct. Use of immunotherapy for cancer treatment is supported by recent clinical trials in acute lymphoblastic leukemia, osteosarcoma and melanoma, suggesting that CAR-T may be an effective approach against other solid tumors. Directing the CAR-T system against extracellular targets on thyroid cancer cells spurs further progress and innovation in pediatric and adult thyroid cancer treatment. Hypothesis: We hypothesize that CAR-T cells targeted against extracellular receptors on papillary and follicular thyroid cells will specifically target and ablate thyroid tissue including well-differentiated thyroid cancer cells. Methods: We established three CAR-T cell lines with anti-TSHR (thyroid stimulating hormone receptor), anti-Tg (thyroglobulin) and anti-NIS (Na+/I- symporter) . By co-culturing GFP-positive tumor cell lines with CAR-T cells and negative controls, cell killing assays were performed to determine effect of extracellular motif-targeting CAR-T cell induced apoptosis. T cells are prepared from full blood samples, then cultured with lentivirus to express the anti-target CAR ectodomain composed of a single chain variable fragment derived from a monoclonal antibody as well as CD28 and ζ-endodomains to mimic costimulatory T cell activation. GFP-positive thyroid cultures prepared for cell killing assays include the papillary thyroid cancer K-1 cell line, follicular thyroid cancer FTC-133 cell line, and a number of primary cultures from fresh thyroid tissue excisions. Results: NIS, TSHR, and Tg were detected by immunof luorescent staining in thyroid cancer tissue. Antibodies used for staining were isolated and sequenced for preparation of targeted CAR-T cell lines. Co-culturing of K-1 or FTC-133 cells with the anti-TSHR CAR-T showed a reduction of GFP intensity, indicating cell killing. Significant killing was confirmed with Caspase 3 and 7 assays. We observed a 2.5 fold increase in killing in K-1 cells and 2.2 fold increase in killing in FTC-133 cells with anti-TSHR CAR-T cells compared to non-specific CAR-T cells. FALL 2016


Conclusion: As well-differentated thyroid cancer cells express at least three distinct extracellular protein motifs, targeting to thyroid tissue is achievable using the CAR-T cell construct to induce selective ablation of thyroid tissue. For patients with differentiated thyroid cancer refractory to traditional therapies, CAR-T presents an opportunity for a potentially efficacious new treatment option. Further studies in vivo are expected to document any adverse effects and therapeutic index.

POSTER PRESENTATION – 2ND PLACE THE EFFECT OF MATERNAL SMOKING ON CFTR FUNCTION OF THE NEONATE Presenting Author: Lydia McCormick Lydia L. McCormick1, Niroop Kaza2, Li Ping Tang1,2, Lawrence Rasmussen2, Stephen Byzek2, S. Vamsee Raju1,2, Steven Rowe1,2. 1Department of Medicine, 2The Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA. The cystic fibrosis transmembrane conductance regulator (CFTR) is crucial for proper airway, pancreatic, and reproductive tract function by regulating chloride and bicarbonate secretion on the epithelial surface. Cystic fibrosis (CF), an autosomal recessive disorder, is a consequence of defective CFTR function and results in a marked host defense defect that includes deficits in airway mucociliary clearance, chronic bronchitis, bacterial infections, and other systemic manifestations. Even in the absence of genetic CFTR mutations, CFTR dysfunction has also been demonstrated in individuals with smoking-related illnesses like chronic obstructive pulmonary disease (COPD) by a process termed “acquired CFTR dysfunction.” The underlying mechanism causing acquired CFTR dysfunction has been linked to toxic metabolites found in cigarette smoke and the circulation of smokers. Among these is acrolein, which has been shown to cause a spectrum of biochemical effects including ciliotoxicity, oxidative stress, transcription factor activation, and cell death. Moreover, previous work from our lab suggests acrolein is the key constituent of cigarette smoke responsible for altered CFTR function in cigarette smokers. The adverse effects of passive smoke exposure on infants is already well understood to contribute to impaired respiratory function and increased infection risk that can persist into childhood. We hypothesize that acrolein passes from the blood circulation of a smoking mother to the fetus thus damaging neonatal CFTR. Although the noxious effects of smoking on CFTR function are well supported in adults, whether smoking and its systemic constituents affect CFTR function in newborns during gestation has not be explored. Specifically, we utilized a rat model of smoke exposure to investigate whether smoking causes damage to fetal CFTR expression and function in the fetus via trans-placental transmission of acrolein. Pregnant rats (n=8) were exposed to cigarette smoke for four hours a day, five days a week, for 10 days prior to fertilization and throughout their 21-23 day gestation period using a whole body exposure chamber and smoking apparatus (SCIREQ, InExpose model, Toronto, Canada). Air-exposed control rats (n=4) were placed in identical chambers for the duration of each smoke session of the experimental group. The pregnancies of each group have been successful and data collection is currently underway. Ex vivo studies after birth will involve measuring CFTR activity in excised trachea by short circuit current analysis to evaluate epithelial ion transport. This will be supported by evaluation of CFTR activity in vivo by potential difference measurement in nasal epithelium (nasal PD, NPD). To establish mechanism and test the role of acrolein, blood will be analyzed for acrolein and other reactive aldehyde constituents by mass spectrometry immediately post-partum, day 1, and day 3 of life; biochemical studies will follow. Results could explain why infants of smokers are predisposed to respiratory infection, even in the absence of ongoing exposure after birth.



POSTER PRESENTATION – 3RD PLACE TREATMENT OF PEDIATRIC ABDOMINAL ANGIOSARCOMA WITH CYTOREDUCTIVE SURGERY AND HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY Presenting Author: Lindsey Winer Lindsey Winer, BS1, Abdullah Alfawaz, MD1,2, Maria Bastos, MD1,3, Juan E. Sola, MD1,5, Andrew E. Rosenberg, MD1,4, Holly L. Neville, MD1,5, Mecker G. MÜller, MD, FACS1,6 1University of Miami Miller School of Medicine, Miami, FL, USA 2Jackson Memorial Hospital Surgery Residency 3 Department of Radiology, Division of Pediatric Radiology 4Department of Pathology 5DeWitt Daughtry Department of Surgery, Division of Pediatric Surgery 6DeWitt Daughtry Department of Surgery, Division of Surgical Oncology Purpose: Angiosarcoma is a rare, but highly aggressive tumor arising from vascular endothelial cells, with a five-year overall survival rate of 35%. Peak incidence of abdominal angiosarcoma is in the seventh decade of life, and very few cases have been reported in the pediatric population. Due to the sparse literature regarding the management of abdominopelvic angiosarcomas in the pediatric population, there are no formal guidelines for treatment at this time. Additionally, there are currently no reported cases of angiosarcomas treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the literature. Methods: We report the case of an adolescent girl who developed a pelvic epithelioid angiosarcoma treated with neoadjuvant chemotherapy, CRS and HIPEC. In addition, we conducted a systematic review of the current literature from 1990 to 2016 to investigate primary and secondary abdominopelvic angiosarcoma in the pediatric population and the treatment outcomes with CRS and HIPEC. Results: A post-menarchal 13-year-old girl presented with refractory malignant ascites. Imaging and diagnostic laparoscopy revealed a widely metastatic pelvic angiosarcoma that appeared to arise from the right ovary. The patient received one cycle of doxorubicin and cyclophosphamide, followed by four cycles of doxorubicin, ifosfamide and mesna, resulting in a partial response with resolution of ascites. The patient then underwent extensive CRS and HIPEC with mitomycin C. The patient had an uneventful peri- and post-operative course. Surgical pathology revealed foci of high-grade epithelioid angiosarcoma. Overall, 70% of the tumor appeared to show treatment effect and 30% was viable. Our literature review demonstrated the efficacy of CRS with HIPEC in treatment of diffuse multifocal abdominal disease from sarcomatous origin. CRS with HIPEC increases disease free survival (DFS) and overall survival (OS) in pediatric patients with peritoneal sarcomatosis. Pediatric patients who treated peritoneal cancer with HIPEC had a three year OS of 71%, compared to 26% and 62% with chemotherapy alone and surgery alone, respectively. Additionally, the only survivors at 3 years from time of diagnosis were those that had the addition of the HIPEC. Conclusion: There is little literature regarding the management and treatment of abdominopelvic angiosarcomas in the pediatric population. Although there is no standardized treatment protocol, and CRS and HIPEC has never been used to treat pediatric angiosarcomas, our experience suggests that CRS and HIPEC is a safe, reasonably tolerated treatment modality in pediatric patients with extensive abdominal metastasis from angiosarcoma origin. We propose the creation of a multiinstitutional registry to evaluate the role of CRS and HIPEC in inducing remission of abdominopelvic angiosarcomas in the pediatric population.

FALL 2016


First Annual Pediatric Resident Advocacy Forum The Future of Pediatric Practice 2016, FCAAP’s annual conference, hosted the first annual FCAAP Pediatric Resident Advocacy Forum. Abstracts were submitted by residents from five different programs. Each resident attended FCAAP’s annual conference at Disney’s Grand Floridian Resort and Spa over Labor Day weekend to present their abstract. The participating residents discussed their projects with conference attendees using poster displays Saturday evening and orally presented their project findings during sessions throughout the weekend. A team of pediatricians reviewed each of the submitted abstracts to select the top three, all of whom received certificates commemorating their achievement during the Saturday afternoon luncheon. The luncheon sponsor, Johns Hopkins Medicine All Children’s Hospital, graciously donated its presentation time during the luncheon to the residents with the top three abstracts- all of whom gave oral presentations during the luncheon. The following abstracts were presented as part of FCAAP’s first annual Pediatric Resident Advocacy Forum:




Implementation of “Brush, Book, Bed” Program in USF Resident Continuity Clinics

Kimberly M. Law, MD, PGY-4; Jeniffer Takagishi, MD; Tracy Burton, MD; Michelle Blanco, MD

University of South Florida Pediatric Residency Program affiliated with Tampa General Hospital and Johns Hopkins All Children’s Hospital

Development and Implementation of a Multidisciplinary, Resident-Led Advocacy Initiative Addressing Poverty Within A Free-Standing Children’s Hospital

John Morrison, MD PhD, PGY-3; Sarah Marsicek, MD, PGY-2; Raquel Hernandez, MD, MPH

Johns Hopkins All Children’s Hospital Pediatric Residency Program

Identification of the most common preventable mortality in previously healthy pediatric patients in Jacksonville, Florida

Emmanuel Pena, DO, PGY-6; Jose Irazuzta, MD,

University of Florida – Jacksonville – Forensic Pediatrics Division; Wolfson Children’s Hospital, Child Abuse Pediatrics Fellowship Program

Readers Are Leaders: an Advocacy Project to Increase Pediatric Literacy

Andrea M. Horbey, DO, PGY-2; Julia Kaplan, DO, PGY-3

Pediatric Residency at Broward Health Medical Center

Incidence and risk factors of pleural empyema in children at two hospitals in Port-au-Prince, Haiti: A retrospective study

Renée ALCE, PGY-3

Pediatric Residency Program Hopital Saint Damien/Hopital Bernard Mevs Universite Notre Dame D'haiti

Congratulations to all of the residents who participated in the 20106 Pediatric Resident Advocacy Forum and thank you to Dr. Jose Zayas and his team for developing the abstract submission guidelines and for reviewing the submissions. The abstracts of the top three residents are published here. First Place: Implementation of “Brush, Book, Bed” Program in USF Resident Continuity Clinics, by Kimberly M. Law, MD, PGY-4; Jeniffer Takagishi, MD; Tracy Burton, MD; and Michelle Blanco, MD, from the University of South Florida Pediatric Residency Program affiliated with Tampa General Hospital and Johns Hopkins All Children’s Hospital. Second Place: Development and Implementation of a Multidisciplinary, Resident-Led Advocacy Initiative Addressing Poverty Within A Free-Standing Children’s Hospital, by John Morrison, MD PhD, PGY-3; Sarah Marsicek, MD, PGY-2; and Raquel Hernandez, MD, MPH, from Johns Hopkins All Children’s Hospital Pediatric Residency Program. Third Place: Identification of the Most Common Preventable Mortalityin Previously Healthy Pediatric Patients in Jacksonville, Florida, by Emmanuel Pena, DO, PGY-6; and Jose Irazuzta, MD, from the University of Florida – Jacksonville – Forensic Pediatrics Division; Wolfson Children’s Hospital, Child Abuse Pediatrics Fellowship Program.



IMPLEMENTATION OF “BRUSH, BOOK, BED” PROGRAM IN USF RESIDENT CONTINUITY CLINICS Kimberly M. Law, MD, PGY-4 Chief Resident, Jeniffer Takagishi, MD, Tracy Burton, MD, Michelle Blanco, MD, Program: University of South Florida Pediatric Residency Program affiliated with Tampa General Hospital and Johns Hopkins All Children’s Hospital Objectives: Dental caries are the most common chronic childhood disease, yet most are preventable. Pediatricians play an important role in children’s oral health since many do not regularly visit a dentist. Less than 30% of patients with Medicaid insurance received at least one preventative dental visit in the past year. “Brush, Book, Bed (BBB)” is an American Academy of Pediatrics program aimed at improving children’s health by creating a nighttime routine of brushing the child’s teeth, reading together and setting a bedtime. Our USF resident continuity clinics primarily care for minority children insured by Medicaid. The aim of this QI project was to introduce the program in resident clinics, then assess for changes in our patients’ dental hygiene, literacy and sleep habits. Methods: During a noon conference, residents were educated to review key points of dental hygiene, reading, and sleep habits with parents and children during the anticipatory guidance portion of all well child visits and to apply fluoride varnish to patients’ teeth. BBB Posters were displayed in the office. Families of patients over four months were given a survey at the beginning of the visit to evaluate the child’s dental, sleep and reading practices at home. Families then received a handout with key points, a ROR book, a toothbrush and fluoridated toothpaste. A follow-up survey is currently in distribution to assess the effect of the BBB message on families’ practices at home. Results: Our population was 24% less than 12 months old, 49% 12 months to 3 years and 27% over 3 years. 78% own a toothbrush. 46.5% have teeth brushed twice per day with 28.4% not having their teeth brushed at all. 26.1% of children do not have assistance when brushing. 34% drink tap water and 78.4% drink juice with 44.3% drinking in bed. 19.3% have been to a dentist. 79% have a bedtime with only 9% do not have books read to them. Discussion: Our results reveal the majority of our patients do not have a dental home, with 80.7% never seen by a dentist, despite 76% being over the recommended age to establish care with a dentist. This reinforces the pediatrician’s crucial role in both dental screening and provision of appropriate anticipatory guidance to all patients. Another alarming finding is that 61% of our patients do not drink tap water, which is fluoridated in Hillsborough county where most of our families live. These children miss the opportunity to receive some cavity prevention daily, underscoring the need for pediatricians to apply fluoride varnish at least every 6 months. Other areas for improvement include education about frequency of brushing, not drinking after bedtime, and avoiding juice. The majority already regularly read to their children and have an established bedtime. Our follow-up survey will inform the areas of the BBB program in which to work next to improve our patients’ dental health, early literacy and sleep practices via implementation of BBB in our resident continuity clinics.

FALL 2016


DEVELOPMENT AND IMPLEMENTATION OF A MULTIDISCIPLINARY, RESIDENT-LED ADVOCACY INITIATIVE ADDRESSING POVERTY WITHIN A FREE-STANDING CHILDREN’S HOSPITAL John Morrison, MD PhD, PGY-3, Sarah Marsicek, MD, PGY-2, Raquel Hernandez, MD MPH, Faculty Advisor, Program: Johns Hopkins All Children’s Hospital Pediatric Residency Program Background: Though the ACMGE mandates that pediatric residency programs engage residents in advocacy and community efforts, there is little guidance pertaining to how to provide all trainees with meaningful experience related to the design and implementation of such efforts. The population served within our training institution includes >75% Medicaid eligible families where many patients are affected by poverty. Following the AAP’s 2014-16 FACE Poverty initiative, residents within our program initiated an educational campaign targeting inter-professional staff across our hospital. Priorities included engaging all interested trainees in the design and implementation of the campaign, as well as educating physicians, nurses and other staff about various aspects of poverty including food security, barriers to health care access, community resources, and educational disparities. Objectives: To develop and implement an inter-professional, hospital-wide advocacy initiative focused on enhancing poverty awareness for all pediatric providers. A secondary objective included engaging our pediatric residents in the design of an educational advocacy campaign where various expertise including public speaking, community relations and social media skills were leveraged from involved residents. Methods: The advocacy initiative resulted in a 7-day educational event held at our institution. Our AAP resident delegates, residents from all training levels, leaders within medical education, hospital executive leadership, marketing/branding, and community relations were engaged in the initiative. Educational materials were developed by our residents and highlighted screening instruments for identification of poverty and offered tools endorsing community-based resources. Daily, thematic educational forums were offered by residents to enhance access to inter-professional teams including an institutional grand rounds session. The effect of the initiative was assessed by evaluating pre/post-provider comfort level with identifying and providing resources for poverty using a Likert-based survey. Utility and interest in the initiative was also assessed via Twitter Analytics. Results: At least 226 hospital faculty and staff were directly engaged during the resident-led face-to-face outreach lunchtime sessions. An additional 111 individuals were present for the advocacy-focused grand rounds session offered during the weeklong initiative. Furthermore, the initiative was viewed on over 5,000 Twitter feeds in six different states over a ten-day period. Medical provider confidence in referring patients to community resources, identifying food insecurity, and helping patients seek health insurance increased significantly after the advocacy initiative. Finally, over half of the trainees in the program were successfully engaged in various aspects of the initiative. Discussion: Advocacy is an important competency for pediatric trainees, however obtaining purposeful experience for trainees is difficult to achieve. We successfully implemented a hospital-wide, resident-led advocacy initiative that directly improved providers’ confidence in addressing multiple poverty-related issues. Many of our residents additionally gained advocacy-related experiences utilizing both in-person, public speaking, and social media-based interventions. Based on the success of this project, our residency program is implementing an annual advocacy curriculum that will provide residents with practical experience in developing and executing advocacy efforts.



IDENTIFICATION OF THE MOST COMMON PREVENTABLE MORTALITY IN PREVIOUSLY HEALTHY PEDIATRIC PATIENTS IN JACKSONVILLE, FLORIDA Emmanuel Pena, DO, PGY -6, Jose Irazuzta, MD, Program: University of Florida – Jacksonville – Forensic Pediatrics Division; Wolfson Children’s Hospital, Child Abuse Pediatrics Fellowship Program Background: The unexpected and preventable death of a healthy child not only has an emotional impact on the family and community, but also creates a long-term financial burden on society. Based on the Jacksonville, FL child death review of 2014, 70 healthy children died from a preventable incident. While it is useful to track causes of child deaths, the child fatality review process is potentially limited by variable approaches in different communities, available resources, and legislative changes. Recurrent changes to this process have a direct impact in how “preventable pediatric deaths” are assessed, and how these deaths are reflected on state records. Objective: If these tragic events can be quantified, a cost-benefit ratio for preventive measures can be established. Identifying the most frequent causes of death in healthy children living in this community would highlight significant pediatric healththreats that are being overlooked by health-policy makers, and aid health officials establish prevention goals, priorities, and strategies to meet the health needs of families in Jacksonville. Methods: A ten-year, 2005-2015, retrospective review of pediatric deaths in the Jacksonville area was done to generate a database. The data combined all death records from Wolfson Children’s Hospital Pediatric Emergency Department, Pediatric Intensive Care Unit, and Duval County Medical Examiner’s Office (ME). Only children ages 2 weeks-old to 12-years-old with a confirmed residential address in the Jacksonville area were included in the analysis. Children with a known chronic medical condition that could have contributed to their death were excluded. Results: Based on the final analysis of the data, unsafe sleeping practices, such as bed sharing (adult with infant) and prone sleeping, was identified as the most common preventable deaths (estimated 35.3%) in previously healthy children in Jacksonville. Accidental trauma and drowning were found to be the cause of death in approximately 29% and 12% of the cases, respectively. Conclusion: Unsafe sleeping practices was the most common cause of death in previously healthy children in the Jacksonville area over the past decade. Aside from the data revealing this unexpected finding, it also showed a considerable increase in unsafe sleeping deaths over the last four years. Additional studies are being designed to analyze the cost-effectiveness of prevention initiatives, the disability-adjusted life year (DALY) involved in this type of death, and to address the incorrect categorization of unsafe sleep deaths as SIDS, SUID, or co-sleeping.



The 2016 FCAAP Brain Bowl Brainiacs from each of the nine pediatric residency programs in our state met at Walt Disney World’s Grand Floridian Resort and Spa on September 4, 2016, to compete in The Florida Chapter of the American Academy of Pediatrics’ second annual Brain Bowl. The Brain Bowl battle of wits closed FCAAP’s two-day annual conference – The Future of Pediatric Practice 2016. After a fierce battle, Florida Hospital – Orlando earned the title of Statewide Champion 2016 and took home the coveted Brain Bowl. After accepting their place as the Statewide Champion of 2016, Tiffany Tamse, MD, the Assistant Program Director at Florida Hospital – Orlando and coach of the winning team, stated: The Florida Hospital Brain Bowl team would like to thank all of the sponsors of this wonderful event. It was a privilege to gather together with all of the Florida Pediatric Residency Programs for a friendly competition. We have some very smart and passionate future pediatricians in our state! Winning the Brain Bowl was a great honor and is especially important to us being such a new program who just graduated our first class this past June! We are happy to have our program stand out and are motivated to keep up our reputation as a strong competitor in future Brain Bowls! The Brain Bowl had a makeover this year. The format was changed to more closely reflect the famous TV gameshow, Jeopardy. There were three preliminary rounds, each with six categories, thirty clues, and a final Jeopardy. The winner from each round moved into the final round. The team from Florida Hospital –Orlando was joined in the final round by a team from Nicklaus Children’s Hospital / Miami Children’s Health System and a team from the University of Miami – Jackson Memorial Holtz Pediatrics. The winning Brainiacs, Drs. Hafid Mantilla, Jennifer Arble, Jordan Schneider, and Wendla Sensing, were coached by Dr. Tiffany Tamse. 22


As the 2016 Statewide Brain Bowl Champion, Florida Hospital – Orlando will be able to display the Brain Bowl trophy at its program for the year. Each member of the team also received a certificate to commemorate the event as well as a gift basket donated by the Dairy Council of Florida. There were plenty of “brain” prizes for all of the competing Brainiacs, as well as delicious pre-game Brain fuel snack for the Brainiacs and audience members provided by the Dairy Council of Florida. In total there were 36 participating Brainiacs, with four Brainiacs from each residency program comprising a team. The teams were:




Florida Hospital Orlando

Drs. Hafid Mantilla, Jennifer Arble, Jordan Schneider, Wendla Sensing

Nicklaus Children’s Hospital / Miami Children’s Health System

Drs. Jason Jackson, Subhrajit Lahiri, Jessica Asencio, Melissa Campbell

Dr. Beatrice Cunnill, Program Director

University of Miami - Jackson Memorial Holtz Pediatrics

Drs. Abhishek Chakraborty, Shivaani Mahabir, Matthew Rumsey, Yonique Petgrave

Dr. Barry Gelman, Program Director

John’s Hopkins Medicine All Children’s Hospital

Drs. Paul Gilbert, John Morrison, Noura Estephane, Marianna Theodoro

Dr. Raquel Hernandez, Program Director

University of Florida Pediatric Residency – Pensacola

Drs. Mudasser Ibrahim, Vignesh Nayak, Osman Altun, Christine Pham

Dr. James Burns, Program Director

University of Florida, College of Medicine – Gainesville

Drs. Brittany Bruggeman, Nancy Joseph, Punitha Jayaramaraju, Jim Buscher

Dr. Nicole Paradise Black, Program Director

University of Florida College of Medicine - Jacksonville / Wolfson Children’s Hospital

Drs. Lindsay Cadorette, Amr Matoq, Laura Travers, Nicolas Chiriboga

University of Florida at Orlando Health

Drs. Mariam Zeini, Summer Vu, Kathleen Vazzana, Betty Cheney

Dr. Jerome Chen, Program Director

University of South Florida Pediatrics

Drs. Kejal Desai, Joanna Robles, Kelsey Schuetter, Sean Butler

Dr. Sharon Dabrow, Program Director

Dr. Stacy McConkey, Program Director Dr. Tiffany Tamse, Assistant Program Director and Team Coach

Dr. Jose Zayas, Program Director (Dr. Ayesha Mirza, incoming Program Director)

These Brainiacs represent our brightest pediatric residents from around the state and the future of FCAAP. The Surgeon General of the State of Florida, Dr. Celeste Philip, was present and recognized our residents for their academic prowess. The judges played a key role in the execution of the Brain Bowl. Dr. Jeffrey Winer (of Jacksonville) and Dr. Nicole ParadiseBlack (of UF Gainesville) served as the Content Judges, Tina Smith (of Jacksonville) served as the official “buzzer,” and Carol Jones (of All Children’s Hopsital) was the official score keeper. The 2016 Brain Bowl was sponsored by Johns Hopkins Medicine All Children’s Hospital and received additional support from the Dairy Council of Florida. Dr. Jose Zayas, Residency Program Director at UF Jacksonville and Host of the FCAAP Brain Bowl, commented on the 2016 Brain Bowl, stating “Everyone had a ton of fun - the audience and the participants. What a great way to bring all of our training programs in the state. Next year we hope to have a resident forum to present resident-specific topics, recognize resident scholarship and most importantly to work on a state-wide advocacy initiative.” We hope to see all of our Brainiacs back next year.

FALL 2016




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