As part of residency training at UW, all residents complete a scholarly project that will challenge them to answer a hypothesis-driven question generated by their interests. Opportunities include:
- laboratory and clinical research;
- quality improvement;
- advocacy projects that include a question and outcome; and
- educational research projects.
At the American Family Children’s Hospital and University Hospital, residents have access to a seemingly unlimited number of research groups, as well as the UW Institute for Clinical and Translational Research. Researchers have been awarded hundreds of millions of dollars of grant money to further medical advances in their fields.
Our department provides a variety of support for resident scholarly projects, including:
- a faculty mentor who will guide and provide support during all stages of your project;
- guidance for grant applications (if needed), protocol development, and IRB approval;
- access to a biostatistician while developing your project and analyzing results;
- funding for residents to attend national meetings to present their work;
- the option to use elective time for dedicated research work; and
- workshops to aid in the creation of abstracts and posters.
Resident Scholarly Week
Each spring, the department holds a Resident Scholarly Week. Residents attend teaching sessions on:
- how to present your work at a national meeting;
- case studies in research ethics; and
- incorporation of research into one’s career.
Research Day ends Resident Scholarly Week and focuses on scholarly work from residents, fellows, and faculty. The event consists of:
- an all-day poster presentation;
- a keynote address by a pediatric faculty member; and
- a series of oral presentations on select topics.
Recent Resident Academic Projects
Risk Factors and Socioeconomic Indicators of Iron Deficiency Anemia in Children Under 5 Years of Age in Rural Imo State, NigeriaAccepted for presentation at the Consortium of Universities for Global Health Annual Conference 2017
Jennie G. Godwin
Background: Iron deficiency is the most common nutritional deficiency and hematologic disease of children worldwide. A humanitarian medical outreach conducted by Mezu International Foundation (MIF) in rural South-Eastern Nigeria noted a high prevalence of childhood anemia associated with severe malnutrition and chronic illness. This study seeks to determine the prevalence of anemia in children less than five years of age and identify modifiable socioeconomic and health risk factors associated with anemia.
Methods: A cross-sectional study was done on 35 randomly selected children under 5 years old, at the MIF medical outreach following Institutional Review Board approval from a collaborating local institution, Federal University of Technology, Owerri, Imo State, Nigeria. A questionnaire was administered to caregivers addressing socio-economic status (SES), dietary iron intake, and knowledge of anemia. Participants received detailed medical exams by licensed physicians. Hemoglobin (Hgb) was measured with a hemoglobinometer. Anemia was defined as a hemoglobin less than 11.0 g/dl, with severity of anemia stratified as mild (10.0-10.9 g/dl), moderate (7.0-9.9 g/dl), and severe (<7.0 g/dl) per WHO standards.
Findings: Out of 35 subjects, 12 male (34%) and 23 female (65%), fifty-four percent were anemic (17% mild, n=6, 29% moderate, n=10, and 8.5% severe, n=3). Hgb (mean±SD) was 8.1±2.1 g/dl in children < 1 year old, (n=7), and 10.6±1.8 g/dl in those 1-4 years old (n=28). There was a significant association between age and diagnosis of anemia (P=0.02). All patients (100%) had a middle SES score. Eighty-two percent of caregivers did not know the meaning of anemia, and 94% did not know causes of anemia. There was a positive correlation between hemoglobin levels and amount of dietary iron intake (r=0.36, P=0.03). Thirty-four percent were currently breastfeeding (71% < 1 year old); and there was a significant association between age and breastfeeding (P=0.03).
Interpretation: Despite middle-income status, families surveyed had poor knowledge of anemia. Children with lower dietary iron intake and breastfed infants less than 1 year old were more anemic than older children. An educational program incorporating recommendations for sustainable local iron-rich dietary options for both children and breastfeeding mothers would aid in alleviating the burden of iron deficiency anemia in this community.
Resident and attending success at lumbar puncture in term neonates
Derek R. Spindler, MD
Sadie J. Skarloken, MD
Background: It is important for physicians to perform successful lumbar puncture (LP) in order to obtain cerebral spinal fluid (CSF) in the workup of febrile neonates. Recent studies indicate that opportunities for residents to perform LP are decreasing and a corresponding decline in resident success with LP1. Furthermore, simulation practice may not improve success rates. We sought to determine if resident LP success rate is indeed lower than that of attending physicians. We hypothesize that because attending physicians have more experience and likely trained in an era with more LP opportunities, their success rates are higher than recent residents. To our knowledge no prior studies have compared attending and resident LP success rates.
Methods: Charts of infants < 30 days old admitted from 2001 through 2015 were identified in our electronic database using institutional coding for lumbar puncture, CSF lab studies, and blood cultures. Blood culture was queried to capture children with failed LPs who subsequently did not have LP billing or CSF results to trigger identification for the study. We recorded success in obtaining CSF in the first LP session, number of needle insertions required per session, and training status of the procedure provider. Success was defined by any lab report of CSF. Success rates based on training status were compared using a Chi-square test.
Results: We identified 184 patients undergoing LP during the study period, with a first-session failure rate of 27.2%. Residents were successful 70.1% of sessions vs. 87.1% for attendings (Chi-square P-value = 0.050). For LP sessions in which the number of spinal needle insertions was reported, there were a mean of 2.14 insertions with median of 2 insertions per session.
Conclusions: Over the study period, resident physicians were less likely than attendings to have a successful LP attempt. Further analysis of success rate trends over time, and specific patient and provider characteristics may reveal reasons for lower resident success other than lack of experience. This data may provide insight into future interventions to increase resident LP success rate.
Completion angiogram may be superior to transesophageal echocardiogram for detection of pulmonary artery residual lesions in congenital heart disease surgery
Erick E. Jimenez Granados
Background: Evaluate if completion angiography is more effective than transesophageal echocardiography at detecting of residual pulmonary artery lesions.
Methods: Retrospective review of 19 surgical cases involving the pulmonary vasculature that had postoperative transesophageal echocardiography and completion angiography from February 2014 to February 2017. Transesophageal echocardiograms were interpreted by two physicians blinded to surgical and completion angiography results. Transesophageal echocardiograms were categorized as adequate repair, inadequate requiring revision or unable to assess. Transesophageal echocardiograms data was compared to results of the completion angiography and to operative notes to determine the ability of each method to detect significant residual lesions.
Results: Mean age 5.4 months and mean weight 5.9 kg. Diagnosis included single ventricle variants (n=14), tetralogy of Fallot variants (n=4) and corrected transposition (n=1). Surgeries included: Glenn operation (n=8), pulmonary artery reconstructions (n=4), main pulmonary artery banding (n=4) and bilateral pulmonary artery banding (n=3). Surgical revision was indicated in 2 of 19 cases by TEE results versus 6 of 19 by completion angiography. Sensitivity of TEE to detect residual lesions of the pulmonary arteries was 40% (95% CI: 12-77%), specificity 100% (95% CI: 78-100%). Positive predictive value was 100% (95% CI: 34-100%) and negative predictive value was 80% (95% CI: 55-93%). Intraoperative angiography related complications included arrhythmia and staining.
Conclusions: Completion angiography may be more effective at detecting post-operative pulmonary artery lesions compared to transesophageal echocardiography. Documentation of pulmonary artery lesions with completion angiography allows immediate surgical revision potentially limiting necessity for future interventions.
The diagnostic challenges of pediatric blastomycosis osteomyelitis: a case seriesManuscript in process
Daniele Y. Gusland, MD
Background: Blastomyces dermatitidis is a dimorphic fungus endemic to the United States and Canada. Though both Histoplasma and Blastomyces are found in similar geographic regions, blastomyces is many times more likely to cause dissemination in the immunocompetent host. Disseminated infection frequently involves the bone. However, given the indolent nature of this fungal infection and the prevalence of more common infectious etiologies of osteomyelitis, diagnosis and treatment is often significantly delayed. Case Report: We review two pediatric cases which initially presented with isolated orthopedic symptoms without documented fever or pulmonary complaints, though both had signs of pulmonary infection on imaging. Discussion: These cases demonstrate the importance of a high level of suspicion as well as appropriate diagnostic work-up, including surgical pathology with fungal stains, when evaluating osteomyelitis in patients exposed to a blastomyces-endemic region.
Echocardiography in the Normal Newborn NurseryPresented at the American Academy of Pediatrics National Conference, 2016
Michael E. Fenster, MD
Background: In the era of improved prenatal detection and universal congenital heart disease screening, we aimed to evaluate the utility of echocardiograms in the normal newborn nursery (NNN).
Methods: This chart review was performed on all newborn echocardiograms performed at one hospital from January 2008 through December 2015. Only the first echocardiogram done on each patient was studied. The studies were screened based on birth weight, ordering provider, and documented indication for study to exclude tests performed in the intensive care unit. The study reports were reviewed to categorize the indication for study, impact on patient care, and primary lesion identified. In addition, nursery physicians were surveyed to determine their specialty, management of murmurs in the NNN, and whether their evaluation of murmurs has changed since completing residency.
Results: 26,565/30,430 infants born at Meriter received their care in the NNN, of which 499 (1.88%) had echocardiograms. The most common indication for echocardiogram was for a murmur (71%), followed by findings on fetal ultrasound (9%). Fifty percent of studies were normal, 42% showed incidental findings, the most common being small VSDs, 6% had abnormalities that may need treatment in the future, but did not change management before discharge, and 2% resulted in some change in care before hospital discharge. Of the 11 infants with a change in management, 3 required transfer to a surgical center and 8 needed only increased monitoring or supplemental oxygen. One of the three requiring surgery was diagnosed on fetal ultrasound, and the other two had loud (3/6 or 4/6) murmurs. The surgical patients included two cases of aortic stenosis and one coarctation of the aorta. Sixty three of 135 (47%) physicians completed the survey. In otherwise asymptomatic infants with a murmur, 30% of respondents order echocardiograms before discharge, 24% would schedule early outpatient follow-up, and 24% would provide routine follow-up with the primary care provider.
Conclusions: In a modern normal newborn nursery, critical congenital heart lesions are rarely identified by echocardiograms. Infants with benign murmurs who are otherwise asymptomatic could safely be followed as an outpatient.
Pulse Oximetry Screening for Critical Congenital Heart Disease in Planned Out of Hospital Births and the Incidence of Critical Congenital Heart Disease in the Plain CommunityPresented at the American Academy of Pediatrics National Conference, 2015, and published in the Journal of Perinatology in 2016
Kathleen K. Miller, MD
Kara S. Vig, MD
Objective: This study evaluated pulse oximetry screening (POS) for critical congenital heart disease (CCHD) in planned out of hospital births with special attention to births in Plain communities (Amish, Mennonite and similar).
Study design: Wisconsin out of hospital births in 2013 and 2014 were evaluated. Care providers were supplied with and trained in the use of pulse oximeters for CCHD screening. State records were reviewed to identify deaths and hospital admissions due to CCHD in this population.
Results: Detailed information on POS was available in 1616 planned out of hospital births. Seven hundred and ninety-nine were from the Plain community. In total, 1584 babies (98%) passed their POS, 16 infants (1%) failed and 16 (1%) were not screened. Five infants from the Plain community had CCHD and three were detected by POS.
Conclusion: POS for CCHD can be successfully implemented outside the hospital setting and plays a particularly important role in communities with high rates of CCHD and where formal prenatal screening is uncommon.Journal of Perinatology advance online publication, 1 September 2016; doi:10.1038/jp.2016.135.
Physician Identification and Documentation of Pediatric Danger Signs at Mbale Regional Referral Hospital: Effect of Refresher TrainingPresented at the Global Health Institute Annual Symposium in Madison, WI, 2017
Kathleen K. Miller, MD
Amanda C. Becker, MD
Background: Appropriate triage and recognition of danger/ priority signs in critically ill children during the first 24 hours of admission is necessary to reduce child mortality, particularly in settings with limited resources. We hypothesized that a quality improvement project at Mbale Regional Referral Hospital (MRRH) to improve provider recognition of danger signs would result in increased documentation of danger signs and indirectly decrease mortality.
Methods: An educational refresher course was held for members of the medical team reviewing paediatric “danger signs” and effective triage. Handouts were given to all participants and posters were placed in the triage area and acute care ward listing defined danger signs. A retrospective chart review was performed to identify documentation of danger signs on admission to the pediatric acute care ward at MRRH for the 2 week period prior to the educational intervention. Data points included the number of danger signs, patient outcome, diagnosis, and length of stay. An additional retrospective chart review assessing the same data points was performed for the 2-week period after the intervention.
Results: 25 clinical staff attended the refresher training. 210 charts were reviewed prior to the intervention and 179 postintervention. The mortality rate in the pre-intervention group was 10%; of these patients, 76% died within the first 24 hours of admission. The average number of positive danger signs identified was 1.0 among patients who survived and 1.8 among patients who died, which was statistically significant (pvalue 0.0015). There was a statistically significant association between the presence of positive danger signs and death (pvalue 0.0048). In the post-intervention group, 179 charts were reviewed in the two weeks following the intervention. 8% of patients had zero danger signs identified. The average number of danger signs identified among patients who survived was 1.7, and 2.7 among those who died (p-value 0.0196). There was a statistically significant increase in the average number of danger signs documented in the pre-vs post intervention group, which averaged of 1.0 in the pre- group and 1.7 in the post-intervention group. Mortality decreased from 10% to 6%, but this was not statistically significant (p-value 0.058).
Conclusions: There was a statistically significant increase in the number of danger signs identified on admission after the educational intervention and placement of visual reminders in the work environment. There was a difference in mortality, although not statistically significant, which may have been related to the number of patients in the study. Refresher trainings for identification of pediatric danger signs lead to increased identification and documentation of danger signs, which could be associated with a decreased mortality over time.
Neonatal post-resuscitation care in rural Ecuador: teaching S.T.A.B.L.E. curriculum to Ecuadorian family medicine residentsAccepted for presentation at AAP 2016
Kathleen K. Miller, MD
Kristy L. Fitzpatrick, MD
Background: The majority of physicians in Ecuador are concentrated in Quito and Quayaqil, the two largest cities, leaving a paucity of providers in rural areas. Hospital Hesburgh in Santo Domingo, Ecuador is the home of a family medicine residency program which aims to provide quality education and training in rural medicine. Hospital Hesburgh also participates in the training of Ministry of Health family medicine residents in surrounding rural areas. These family medicine residents have varying and often limited exposure to neonatal care, yet they will be responsible for the care of ill neonates in these rural settings. Thus, a course addressing neonatal post-resuscitation cares was selected for an educational outreach program in rural Ecuador.
Objectives: The course objective was to enhance knowledge in post-resuscitation neonatal care of Ecuadorian family medicine residents through adaption of the S.T.A.B.L.E. Program, an established course for low-resource settings in the United States. Specific course objectives focused on common neonatal care topics: hypoglycemia, hypothermia, respiratory distress, shock, and infection. The simulation-based portion of the course aimed to improve proficiency in specific skill sets, including bag mask ventilation, intubation, and umbilical catheter placement.
Methods: A total of 9 full 8 hour S.T.A.B.L.E. courses were conducted over 1-2 days in 4 rural Ecuadorian cities (Pedro Vicente de Maldonado, Santo Domingo, Porto Viejo, and Manta). These courses included the 5 core curriculum topics (hypoglycemia, hypothermia, respiratory distress, shock, laboratory analysis) and simulation. The emotional support unit of S.T.A.B.L.E. curriculum was omitted out of respect for cultural differences between Ecuadorian and American institutions. Simulations were adapted to reflect availability of local materials (ie: nasogastric tubes were adapted to be used as umbilical catheters). Written and oral feedback was obtained from course participants by the Ecuadorian family medicine faculty.
Results: A total of 91 family medicine residents completed the S.T.A.B.L.E. course. The average age was 35.5 years with a range of 28-51 years. Majority were female (59%). The average group size was 10, with a range of 4-17 people. All of the groups had improvement in their test score after completion of the S.T.A.B.L.E. course. The average pre-test score was 17.8/27 and the average post-test score was 22.4/27. Overall, feedback from the residents was very positive stating that the course was high-yield and relevant for their future careers.
Conclusion: There was an improvement in the test scores after completing the course, suggesting the residents had gained knowledge of neonatal care. Based on positive feedback and the improvement in test scores, it appears that the S.T.A.B.L.E. program has the potential to be adapted to low-resource settings abroad.
Case report of the natural history of incidentally found medulloblastoma followed radiographically in a young adult with chronic headaches
Nicholas J. Pytel, DO
Research Proposal: Medulloblastoma is a malignant tumor diagnosed in 12-25% of pediatric brain tumors, 77% before the age of 19. In adulthood, the rate sharply declines with increasing age to be only diagnosed in 0.4-1% of adult brain tumors. These tumors are diagnosed typically after symptoms are noted consistent with increased intracranial pressure. We present a case of a young adult who was followed with serial MRI scans due to history of headaches and over time developed a lesion in the cerebellum that was later diagnosed as a medulloblastoma. We present this case as a natural history of medulloblastoma and will include a review of the literature. Patient AG had the original MRI brain scan for chronic headaches yielding only a right posterior fossa arachnoid cyst. Four years later, persistent headaches warranted another scan showing a new lesion with T2 FLAIR hyperintensity in the left cerebellar hemisphere. Serial scans over two years showed progression in size and complexity of this new lesion originally thought benign. AG underwent craniotomy with mass resection that resulted in cytoplasmic beta-catenin positive medulloblastoma without anaplasia on neuropathology. It was also without metastasis or CSF involvement. Post-operative imaging showed a small suspicious area near the resection cavity which biopsies later proved positive for residual medulloblastoma greater than 1.5 cm, thus placing this patient into the high-risk treatment category. AG elected proton therapy (36 in the craniospinal region with posterior fossa boost) with vincristine following protocol ACNS0331 with maintenance therapy afterward. AG has since been followed with serial MRI scans without evidence of residual disease. After reviewing the literature, low occurrences of incidental CNS tumors have been found in trauma and research cases. It is rare to have radiographic evidence of the onset of a malignant brain tumor. We present our case and literature review of this entity.