Cohen Children's Medical Center Research Articles

Evaluation of the Safety and Efficacy of Enoxaparin Once-Daily Versus Twice-Daily Dosing for Prophylaxis in Pediatric Patients.

Enoxaparin for the prevention of venous thromboembolism (VTE) in pediatric patients is -typically dosed twice a day. The use of once-daily dosing like that used in adult patients is limited because of a lack of safety and efficacy data. The aim of this study was to evaluate the safety and efficacy of -once-daily versus twice-daily dosing of enoxaparin for pediatric VTE prophylaxis based on incidence of thrombotic and bleeding events. This was a 3-year retrospective chart review of enoxaparin received for VTE prophylaxis at -Cohen Children's Medical Center, New Hyde Park, NY. Exclusion criteria were age 18 years or older, and renal dysfunction. A total of 177 enoxaparin courses (81 in the once-daily and 96 in the twice-daily group) were included. The median dose in the once-daily group was 0.68 mg/kg/dose with dose capping at 40 mg/dose in 70% of patients. One patient in the once-daily group had a VTE, whereas no patients in the twice-daily group experienced a VTE. One major bleeding event occurred in the once-daily group (p = 0.46); however, minor bleeding events were comparable between the 2 groups (p = 0.69). Once-daily enoxaparin prophylaxis appears to be safe and effective based on minimal -differences in incidence of thrombotic and bleeding events when compared to twice-daily dosing. Based on this study, it may be reasonable to consider once-daily enoxaparin dosing for prophylaxis, especially in older children. A larger multicenter cohort study evaluating once-daily dosing for prophylaxis is warranted to validate the safety and efficacy specifically for risk-based dosing strategies.

Characteristics, course and condition of patients presenting to an adolescent medicine eating disorder program: A three-year study

PurposeEvaluate clinical characteristics at initiation, during, and at discontinuation of care for patients with eating disorders regardless of reason for discontinuation of care. MethodsA chart review of 279 patients who presented to the Division of Adolescent Medicine of Cohen Children's Medical Center (Northwell Health, New York) between May 1, 2014 and April 30, 2015. Demographics and clinical information including anthropometry, last menstrual period (LMP), caloric intake, eating disorder behaviors, length of illness, DSM-5 eating disorder diagnosis was collected from 2734 visits. Results45% of patients had Anorexia Nervosa (AN), 24% had Atypical Anorexia Nervosa (AAN), 15% had Bulimia Nervosa/Purging Disorder (BN/PD), and 17% had Avoidant Restrictive Food Intake Disorder (ARFID). Patients on average were sick for 18 months and lost 20 pounds prior to presentation. Physicians indicated they wanted patients to remain in active treatment in approximately 40% of cases where care was discontinued. The factors, used to predict which patients would have an unsuccessful vs successful outcome (defined as needing vs not requiring frequent care), were analyzed. A history of diet-pill use, purging, and exercise predicted an “unsuccessful outcome” (p = 0.02, p = 0.005, p=0.03, respectively). 32% of the 202 menarchal females lost their menses prior to treatment, and 54% had resumption of menses during treatment. ConclusionsPrevious studies report high dropout rates in treatment of eating disorders across various treatment modalities and focus on those who remain in care. Here outcomes for all patients evaluated and treatment in an adolescent medicine care model are presented and show that a sizable portion, 37%, of those who drop out are recommended to stay in active treatment and only approximately 30% complete treatment. This finding supports an adolescent care model for eating disorder treatment and highlights that most adolescent patients go on to do well after leaving treatment, even if they left care earlier than recommended.

Isolated abnormal FEF75% detects unsuspected bronchiolar obstruction in CF children.

Physiologic detection of bronchiolar obstruction in children with cystic fibrosis (CF) may be clinically unsuspected because of normal routine spirometry despite bronchiectasis on lung CT. Children from two accredited CF facilities had spirometry obtained every 3 months when clinically stable. Pre-bronchodilator maximum expiratory flow volume curves were retrospectively analyzed over 16 years to detect an isolated abnormal FEF75%, despite normal routine spirometry. At Miller Children's and Women's Hospital (MCWH), an abnormal FEF75% was initially detected in 26 CF children at age 7.5 ± 4 (SD) years despite normal routine spirometry initially. FEF75% remained an isolated abnormality for 2.5 ± 1.5 years after it was initially detected in these 26 CF children. At Cohen Children's Medical Center (CCMC), despite normal routine spirometry initially, abnormal FEF75% occurred in 13 children at age 11.7 ± 4.5 years, and abnormal FEF25-75% in 10 children at age 11.8 ± 5.3 years. FEF75% was most sensitive spirometric test for diagnosing both early and isolated progressive bronchiolar obstruction. Data from CCMC in older children demonstrated the simultaneous detection of abnormal FEF75% and FEF25-75% values consistent with greater bronchiolar obstruction when serial spirometry was initiated at an older age. There is very little published spirometric data regarding diagnosis of isolated small airways obstruction in CF children. FEF75% can easily detect unsuspected small airways obstruction in CF children with normal routine spirometry and bronchiectasis on lung CT and optimize targeted modulatory therapies.

255 Delivery of Epinephrine by Metered-Dose Inhaler for the Treatment of Croup in Children

255 Delivery of Epinephrine by Metered-Dose Inhaler for the Treatment of Croup in Children

Longitudinal analysis of cardiac abnormalities in pediatric patients with sickle cell anemia and effect of hydroxyurea therapy

AbstractCardiac abnormalities such as left ventricular hypertrophy, left ventricular dilation, and pulmonary hypertension in sickle cell anemia have been previously described. Hydroxyurea, a disease-modifying therapy for sickle cell anemia, has been used for several decades. Longitudinal assessment of echocardiographic abnormalities in children and young adults with sickle cell anemia receiving hydroxyurea therapy is lacking. The goal of this retrospective study was to determine the prevalence of echocardiographic abnormalities in children and young adults with sickle cell anemia and to examine the effects of hydroxyurea on reverse cardiac remodeling. We reviewed the records of patients with sickle cell anemia who underwent routine cardiac screening at Cohen Children's Medical Center between 2010 and 2017, followed by retrospective longitudinal analysis of echocardiograms performed on patients receiving treatment with hydroxyurea. Data on a total of 100 patients with sickle cell anemia were analyzed; 60 (60%) were being treated with hydroxyurea. Twenty-five (41.6%) of the patients on hydroxyurea had been treated for <1 year; these patients had a significantly greater prevalence of left ventricular dilation compared with those who had been on treatment for >1 year. Serial echocardiograms of patients receiving hydroxyurea were then analyzed. Left ventricular dilation and hypertrophy improved significantly with hydroxyurea treatment. In addition, the left ventricular volume and mass correlated negatively with duration of treatment with hydroxyurea. Our study provides evidence that prolonged hydroxyurea therapy may lead to reverse cardiac remodeling. Future studies should attempt to follow up this patient cohort for a longer duration.

Asthma and COVID-19: An early inpatient and outpatient experience at a US children's hospital.

BackgroundInitially, persistent asthma was deemed a risk factor for severe COVID‐19 disease. However, data suggests that asthmatics do not have an increased risk of COVID‐19 infection or disease. There is a paucity of data describing pediatric asthmatics with COVID‐19.ObjectiveThe objectives of this study were to determine the prevalence of asthma among hospitalized children with acute symptomatic COVID‐19, compare demographic and clinical outcomes between asthmatics and nonasthmatics, and characterize behaviors of our outpatient pediatric population.MethodsWe conducted a single‐center retrospective study of pediatric patients admitted to the Cohen Children's Medical Center at Northwell Health with symptomatic COVID‐19 within 4 months of the surge beginning in March 2020 and a retrospective analysis of pediatric asthma outpatients seen in the previous 6 months. Baseline demographic variables and clinical outcomes for inpatients, and medication compliance, health behaviors, and asthma control for outpatients were collected.ResultsThirty‐eight inpatients and 95 outpatients were included. The inpatient prevalence of asthma was 34.2%. Asthmatics were less likely to have abnormal chest x‐rays (CXRs), require oxygen support, and be treated with remdesivir. Among outpatients, 41% reported improved asthma control and decreased rescue medication use, with no COVID‐19 hospitalizations, despite six suspected infections.ConclusionsAmong children hospitalized for acute symptomatic COVID‐19 at our institution, 34.2% had a diagnosis of asthma. Asthmatics did not have a more severe course and required a lower level of care. Outpatients had improved medication compliance and control and a low risk of hospitalization. Biological and behavioral factors may have mitigated against severe disease.

Improving Operating Room Start Times

Abstract The Pre-Surgical Testing program at Cohen Children's Medical Center launched in 2012. We evaluate approximately 7,000 patients per year who are scheduled for outpatient and inpatient surgeries from all pediatric surgical services. The Pre-Surgical Testing program providers are pediatric and family nurse practitioners (NPs). In 2017, the NP role expanded into the inpatient setting. We started to evaluate patients scheduled for emergency procedures, sedated radiology studies, and invasive procedures. We identified high-risk patients, which provided anesthesiologists with the critical information they needed to deliver safe patient care. In 2018, the NPs further expanded into the ambulatory setting. Our role includes preoperative orders, managing postoperative pain, entering discharge medications, and providing continuing education to nursing staff. From February 2018 to August 2018, first-case start times have improved by 20%. The combination of clinical knowledge and experience makes NPs uniquely qualified to identify high-risk patients scheduled for surgery. Other institutions may consider NPs in their postoperative areas to improve OR start times and, more generally, patient safety.

Comparison of Clinical and Epidemiologic Characteristics of Young Febrile Infants with and without Severe Acute Respiratory Syndrome Coronavirus-2 Infection

ObjectiveTo determine features that distinguish febrile young infants with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.Study designRetrospective single-center study included febrile infants <57 days of age evaluated in the emergency department of Cohen Children's Medical Center of Northwell Health, New Hyde Park, New York, from March 1 to April 30 of 2018, 2019, and 2020. Sociodemographic and clinical features were compared between those seen during the 2020 coronavirus disease-2019 pandemic and previous years, as well as between infants with SARS-CoV-2 infection and infants without SARS-CoV-2 infection (SARS-CoV-2 negative or evaluated during 2018 and 2019).ResultsIn all, 124 febrile infants <57 days of age were identified; 38 during the 2-month study period in 2018, 33 in 2019, and 53 in 2020. During 2020, fewer febrile infants had a serious bacterial infection or a positive respiratory viral panel than in prior years (6% vs 21% [P = .02]; 15% vs 53% [P < .001], respectively). SARS-CoV-2 was the most frequent pathogen detected in 2020; of 30 infants tested, 20 tested positive. Infants with SARS-CoV-2 were more likely to identify as Hispanic (P = .004), have public insurance or be uninsured (P = .01), exhibited lethargy (P = .02), had feeding difficulties (P = .002), and had lower white blood cell (P = .001), neutrophil (P < .001), and lymphocyte counts (P = .005) than the 81 infants without SARS-CoV-2 infection. None of the infants with SARS-CoV-2 had concurrent serious bacterial infection or detection of another virus. Overall, disease in infants with SARS-CoV-2 was mild.ConclusionsDuring the peak of the pandemic, SARS-CoV-2 was the predominant pathogen among febrile infants. Socioeconomic, historical, and laboratory features differed significantly between infants infected or not infected with SARS-CoV-2. None of the 20 infants with SARS-CoV-2 infection had an identified coviral or serious bacterial infection.

Comparison of surgical outcomes in patients with Chiari Type I malformation receiving posterior fossa decompression with and without duraplasty.

The goals of this study were to compare clinical outcomes in patients with Chiari Malformation Type I (CMI) receiving posterior fossa decompression with (PFDD) or without duraplasty (PFD). We conducted a retrospective analysis of 178 consecutive cases of 157 patients undergoing PFDD or PFD for CMI at Cohen Children's Medical Center between 2007 and 2017. Clinical improvement was defined as a clear reduction of preoperative symptoms after surgery as reported by patients and parents. An improvement of syrinx was derived from radiologic comparison of pre- and postoperative MR imaging. Chi-square analysis was performed to analyze the association between duraplasty and clinical parameters (alpha = 0.05). The primary presenting complaint was headache (142/178; 80%), followed by neck, back, and upper extremity pain, and numbness or tingling (49/178; 28%). Seventy patients (78/178; 44%) underwent PFD, and 100 patients (100/178; 56%) underwent PFDD. Overall, 143 patients (143/178; 80%) experienced subjective improvement with no statistically significant difference between the two surgical techniques (p = 0.705). The number of patients receiving PFDD with syrinx improvement or stabilization (55/59; 93%) was statistically larger than those that received PFD (8/13; 62%) (p = 0.008). PFDD was associated with greater complications than PFD alone. There were 35 cases of reoperation overall (35/178; 19%), and there was no statistically significant difference in reoperation rate between PFD and PFDD (p = 0.255). There appears to be a role for PFDD in patients with severe syringomyelia, but overall, PFD alone may be safely offered as the initial surgical intervention for symptomatic CMI patients.

17. A CURRICULUM TO SUPPORT SCHOLARSHIP PRODUCTIVITY IN A PEDIATRIC RESIDENCY PROGRAM

Background Resident scholarly activity is desirable component of a pediatric training program. Frequently cited challenges include mentorship and time. To address these issues the training program at Cohen Children's Medical Center designed a three year process to promote resident scholarly activity through enhanced mentorship and protected time. Objective The objective of this longitudinal curriculum was to increase resident involvement in scholarly activity. Methods In 2013 the pediatric program launched a longitudinal curriculum to promote resident scholarly productivity. The program included the following major curricular elements: (1) A two week research/quality improvement rotation in the PGY1 year. This rotation included individual meetings with senior faculty, completion of 6 on-line research modules, SPSS statistical training, completion of the CITI Course, instruction on the formulation of a research question and the creation of an individual scholarly activity timeline. This was followed by (2) Semiannual Scholarly Oversight Committee Meetings, (3) 1-2 dedicated research blocks for individual residents and an opportunity to present at an Annual Pediatric Resident Research Day. Funding for residents to present at national meetings was made available. Results Scholarly activity, as defined by the number of resident presentations at a national meetings, has increased substantially from 2013-2017. When the curriculum was introduced 7 out of 100 residents had either a poster or platform presentation accepted to a national meeting. This number increased steadily year over year and has reached 40 presentations in 2017. Conclusion A longitudinal curriculum focused on scholarly achievement was successful in increasing resident scholarly output. This curriculum can be easily emulated at other programs to increase resident scholarly productivity.

87. TRANSFORMING ADVOCACY CURRICULA INTO ONE THAT PROMOTES TRAINEE KNOWLEDGE, SKILLS, AND ENGAGEMENT

Background Residency programs have addressed advocacy curriculum needs with various degrees of success. Program leadership at Cohen Children's Medical Center recognized the need to enhance curricula to meet the demands of residents and communities. Design Didactics are structured as a series of conferences, interactive workshops and web-based modules. There is education on the importance of Community Based Organizations (CBOs), health equity, vulnerable populations, legislative advocacy etc. Experiential learning is provided at CBOs, federal program sites, and schools. During this 4-week intern rotation, residents care for vulnerable populations, provide outreach, conduct health assessments, and participate in home visits in a community setting. Each intern develops an advocacy topic/campaign (gun safety, toxic stress, border separation, voter rights) to present at a resident noon conference. To further highlight the importance of this topic, a 3-week advocacy lecture series was incorporated into the core resident education curricula. Results Enhanced understanding of advocacy topics and increased interest in engaging in advocacy initiatives was demonstrated. The mean value-added score for the series was 1.52 (CI 1.35 to 1.7). There was improvement in understanding (decrease in score) within multiple topics. Pre-intervention understanding of public health insurance, school-based clinics, healthcare economics, and CBOs was 2.83, 2.67, 2.89, and 2.25 respectively. Post-intervention understanding of public health insurance, school-based clinics, healthcare economics, and CBOs was 1.61, 1.80, 2.00, and 1.55 respectively (p Conclusion Residents yearn to learn advocacy measures. An advocacy toolkit equips residents with the knowledge and skills necessary to lead and transform future work environments. The curriculum is easily replicable for residency programs desiring to integrate advocacy training curricula without increasing the burden of utilizable resources.

86. EARLY IMPACT OF A HEALTH EQUITY, DIVERSITY, AND INCLUSION CURRICULA ON RESIDENT KNOWLEDGE, ATTITUDES AND SKILL IN CROSS-CULTURAL CARE

Background GME programs that provide targeted training on the care of disadvantaged populations may result in improved cross-cultural care and decreased health disparities and patient discrimination. In 2018, the ACGME highlighted lack of formal education on knowledge and strategies to address health disparities as a national priority need. Currently, many residents do not receive training on structural competencies and biases that contribute to poor health, nor are they equipped with skills to advocate for patients who disproportionately experience inequity from structural and social determinants of health (SDOH). Design The HEDI curriculum at Cohen Children's Medical Center expands resident training to include sessions on: implicit bias, use of interpreters, health literacy, health disparities, community engagement, LGBTQ health, mistrust, racism, SDOH, cultural and structural competency. Prior to curriculum initiation, residents completed the validated Cross-Cultural Care Survey (CCCS). Trainees engage in monthly, interactive workshops and case-based simulations. Pre and post surveys assess resident knowledge, skill, and attitudes related to each session. Descriptive analyses and Fisher's Exact Test assess bivariate associations. Results Of the 49 residents who completed the CCCS, 67% felt unprepared to deliver cross-cultural care. 18% identified lack of experience and 30% reported inadequate training as barriers to delivering cross-cultural care. Attendance of at least 1 HEDI session was associated with a decrease in residents personal feeling of helplessness when caring for patients of different cultures (p Conclusion Early results from the HEDI curriculum show residents' improvement in preparedness and attitudes in providing cross-cultural care. Further research is warranted to examine whether curricular elements provide a long-term, sustained impact on resident knowledge, skills, and attitudes, which are necessary to combat and eliminate health disparities.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

Validation of Lipase and Systemic Inflammatory Response Syndrome as Prognostic Indicators in Pediatric Acute Pancreatitis: A Retrospective Analysis.

Acute pancreatitis (AP) is understudied in the pediatric population despite increasing incidence. Although many cases are mild and resolve with supportive care, severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. There is a lack of pediatric-specific predictive tools to help stratify risk of SAP in children. A retrospective cohort study of patients with AP or recurrent AP at Cohen Children's Medical Center between 2011 and 2016 was performed. Lipase level and the presence of pediatric systemic inflammatory response syndrome (SIRS) on admission were examined as potential predictors of SAP and length of stay (LOS). A multivariate logistic regression or analysis of covariance was used to conduct the multivariate analysis. Seventy-nine pediatric patients met inclusion criteria. Approximately 37% (29/79) had SIRS on admission, 22% (17/79) developed SAP, and there were no mortalities. In both the univariate and multivariate models, SIRS was a predictor of SAP. Mean (SD) LOS for patients with SIRS compared with without SIRS was 9.6 ± 8.3 compared with 6.3 ± 6.9 days (P < 0.05). The mean LOS of patients with one or more comorbidity (48%, 38/79) was 10.0 ± 9.5 compared with 5.2 ± 4.0 days (P < 0.01) for those patients without any comorbidities. Only the presence of comorbidities predicted length of time spent nil per os (NPO; P = 0.0022). Patients with comorbidities stayed an average of 5.6 ± 7.6 days NPO, whereas those without comorbidities spent 2.8 ± 2.4 days NPO. Lipase was not predictive of SAP, LOS, or length of time spent NPO. These results support the use of SIRS as a simple screening tool on admission to identify children at risk for the development of SAP. The presence of any comorbidity was predictive of LOS and length of NPO in the multivariate model. This may reflect that comorbidities prolong pancreatitis or influence disposition planning.

Treatment of Dehisced, Thoracic Neonatal Wounds With Single-Use Negative Pressure Wound Therapy Device and Medical-Grade Honey: A Retrospective Case Series.

The purpose of this study was to report on our experience with a portable, single-use negative pressure wound therapy device used in combination with activated active Leptospermum honey (ALH) in the treatment of colonized or infected, dehisced, thoracic wounds in neonates with complex congenital heart disease. Retrospective, descriptive study. We reviewed medical records of 18 neonates and reported on findings from 11; the remaining 7 were not included secondary to incomplete records, transfer to a different institution prior to wound healing, or death. The median age of our patients was 12 days (range, 2 days to 5 weeks); their mean gestational age was 34 weeks. All of the neonates had acquired postoperative wound dehiscence that were colonized or infected and were treated in the neonatal intensive care unit (NICU) at Cohen Children's Medical Center (New Hyde Park, New York), a regional perinatal center with a level 4 NICU. Wound cultures were obtained on all patients prior to treatment commencement. All cultures were repeated on day 4 of treatment. Systemic antibiotics were administered as necessary. No complications were observed related to the use of negative pressure wound therapy device and ALH. All patients were followed until discharge home or transfer to another facility. The pain scores during placement and removal were acceptable (between 1 and 3; median = 2) using the Neonatal Infant Pain Scale. Staff and parents indicated that the combination of ALH and the negative pressure wound therapy device did not interfere with daily care and parental bonding. Use of ALH and a single-use negative pressure wound therapy device was successful in this series of 11 neonates with complex congenital heart disease.

Burden of Healthcare-Associated Viral Respiratory Infections in Children's Hospitals.

Although healthcare-associated (HA) viral respiratory infections (VRIs) are common in pediatrics, no benchmark for comparison exists. We aimed to determine, compare, and assess determinants of unit-specific HA-VRI incidence rates in 2 children's hospitals. This study was a retrospective comparison of prospective cohorts. The Montreal Children's Hospital and the Cohen Children's Medical Center of New York perform prospective surveillance for HA-VRI using standardized definitions that require the presence of symptoms compatible with VRI and virus detection. Cases detected between April 1, 2010, and March 31, 2013, were identified using surveillance databases. Annual incidence rates were calculated, and a generalized estimating equation model was used to assess determinants of HA-VRI rates. The overall HA-VRI rate during the 3-year study period was significantly higher at Montreal Children's Hospital than that at Cohen Children's Medical Center of New York (1.91 vs 0.80 per 1000 patient-days, respectively; P < .0001). Overall, the HA-VRI incidence rate was lowest in the neonatal intensive care unit. Rates in the pediatric intensive care, oncology, and medical/surgical units were similar. The most common etiology of HA-VRI at both institutions was rhinovirus (49% of cases), followed by parainfluenza virus and respiratory syncytial virus. Hospitals with less than 50% single rooms had HA-VRI rates 1.33 (95% confidence interval, 1.29-1.37) times higher than hospitals with more than 50% single rooms for a given unit type. HA-VRI rates were substantial but different among 2 children's hospitals. Future studies should examine the effect of HA-VRI and evaluate best practices for preventing such infections.

Coblation-assisted management of pediatric airway stenosis

ObjectivesThe treatment of pediatric airway stenosis represents a major challenge for the otolaryngologist. The aim of this study is to evaluate the use of bipolar radiofrequency plasma ablation (Coblation) in the treatment of pediatric airway stenosis. Study designRetrospective case series. Tertiary care pediatric academic medical center. MethodsThe medical records of 6 pediatric patients at Cohen Children's Medical Center from July 2009 to December 2015 were reviewed. All cases involved the use of radiofrequency plasma ablation to address airway stenosis. Patient presentation, surgical intervention(s), post-operative course and complications were analyzed. ResultsAll 6 cases involved pediatric airway stenosis, including glottic stenosis (2), bilateral vocal fold immobility (2), and intratracheal lesions (2). Coblation was used to perform a range of different procedures, including removal of scar/granulation tissue, partial arytenoidectomy, and posterior cordectomy. All patients experienced good results without major complications, perioperative, or post-operative sequellae. ConclusionThe results of this study suggest that radiofrequency plasma ablation may be an effective endoscopic tool for the treatment of pediatric airway stenosis. Further study and more patients are required as this technique becomes increasingly applied.

A Simulated Level Loading of Supply and Demand for Beds in a Tertiary Care Children's Hospital Reduces Overall Bed Requirements.

Anticipating throughput and allocating resources effectively in children's hospitals have unique challenges relative to adult inpatient centers. The seasonal and daily variation can be difficult to anticipate in terms of impact and creating plans for adequate preparation. Discrete event simulation methodology can be helpful in determining appropriate allocation of resources and has been increasingly appropriated in health care from industry. A representative sample set was abstracted from the Cohen Children's Medical Center census tracking system to describe the present state. A larger data set was used to determine the appropriate level load. The total work performed each hour from 8 AM to 8 PM was evaluated against the level load plan of 11.5%. During the initial hours of the working period when the total work was low, more discharges were added. For each discharge added, an equal quantity of discharges was subtracted from the later hours of the day to bring the total work below 11.5% for each hour. Once the simulated state discharges were determined, a new aggregate bed supply line was created. These values were then added to the original visualization to show improvement. Our analysis suggests that a large part of the discharge/transfer activity and bed demand activity occurs in the pediatric intensive care unit in a roughly 4- to 5-hour window. Our simulation analysis suggests that level loading of this resource-intensive activity period has a potential to reduce bed occupancy, increase bed availability in peak bed demand times, and improve efficiency and throughput throughout the hospital. Discrete event simulation can be an effective tool for pediatric inpatient centers to determine appropriate allocation of resources to enhance patient safety and throughput without significant, costly expansion of bed capacity.

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aSteven & Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York bUniversity of Pennsylvania, Philadelphia, Pennsylvania, USA Correspondence to Andrew Adesman, MD, Developmental and Behavioral Pediatrics, Cohen Children's Medical Center of NY, 1983 Marcus Avenue, Suite 1983, Lake Success, NY 11042, New York, USA. Tel: +1 516 802 6112; e-mail: [email protected]

Poster 46: Neonatal Hemochromatosis: The Importance of Minor Salivary Gland Biopsy in Diagnosis. The Cohen Children's Medical Center Experience

Neonatal hemochromatosis (NH) is a rare and severe neonatal liver disease associated with extrahepatic siderosis. A prompt diagnosis of NH is critical, as disease progression is rapid and early treatment is crucial. Consistently involved extrahepatic sites of iron deposition are minor salivary glands. Thus, biopsy of minor salivary gland lobules (MSGL) can offer a simple, low risk, rapid method to help establish a diagnosis. NH is also referred to as gestational alloimmune liver disease. Substantial evidence suggests it is the result of fetal liver injury.