Poster 565 Revitalizing an Inefficient, Ineffective Interdisciplinary Team Meeting on a Pediatric...
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Poster 563 Neurostimulants as a Treatment for Anoxic Brain Injury in a Two-Year-Old Girl with Hereditary Ventricular Arrhythmia: A Case Report. Katarzyna B. Iwan (URMC, Rochester, NY, United States); Denise Norton, MD; Nathan Odom, MD. Disclosures: K. B. Iwan, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient presented with cardiac arrest secondary to CPVT/ARVD resulting in anoxic brain injury. She was initially sedated to prevent further episodes of ventricular ectopy. Sedation was weaned and diffuse cerebral hypoxia was noted on imaging. Four weeks post cardiac arrest, the patient was initially titrated on Nuvigil due to the lower side effect profile and showed improvement in eye tracking and head control. She was then transitioned to Provigil and finally Ritalin and regained further brain function. On discharge, the patient continued to make functional progress without further episodes of ventricular tachy- cardia while on neurostimulants. Setting: Acute inpatient rehabilitation unit in tertiary care hospital. Results or Clinical Course: At 1 month, 3 months and 6 months post administration of neurostimulants, the patient continued to regain neurological function. Her therapists have noted improvements in postural control, balance, motor function, coordination and communication. Discussion: CPVT and ARVD represent a hereditary ventricular tachycardia postulated to cause up to 15% of sudden cardiac deaths in the pediatric population due to a mutation in voltage gated ion channels. Optimal management of CPVT/ARVD includes initial sedation to prevent endogenous catecholamine release and ventricular ectopy. In contrast, brain injury is managed with neurostimulants which promote cholinergic activity. Moreover, there is no FDA approved neurostimulant dose that can be administered to patients under six years old. To our knowledge, this is the first reported case of neurostimulant use in a patient under six years old with hereditary ventricular tachycardia and anoxic brain injury. Conclusions: Neurostimulant use for treatment of brain injury in children with ventricular arrhythmia is possible despite the cholinergic side effects and no approved pediatric dosing. Poster 564 Knee Disarticulation Followed by Acute Inpatient Rehabilitation Resulting in Significant Functional Improvement in a Child with Congenital Fibular Hemimelia and Neurofibromatosis: A Case Report. Gregory P. Burkard, DO (NYU, Montauk, NY, United States); Dellene E. Troy; Christopher V. Boudakian, DO; Renat Sukhov, MD. Disclosures: G. P. Burkard, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The case describes a 5-year-old male who met most developmental milestones, except was limited to army style crawling his entire life. Due to psychosocial reasons, the mother opted against an amputation and preferred a right achilles tendon lengthening at the age of 1 for equinovalgus deformity. Despite aggressive outpatient physical therapy, the patient never gained the ability to functionally ambulate, so he was limited to home school for convenience. The decision was made to undergo a knee disarticulation and prosthetic fitting to give the boy an opportunity to ambulate. Setting: Pediatric Acute Inpatient Rehabilitation Facility (IRF). Results or Clinical Course: On day of receiving prosthesis, he ambulated 30 feet with moderate assistance for advancing pros- thetic and maximum assistance for locking and unlocking knee unit while using a rolling walker. He performed basic transfers with contact guard assistance (CG) and donned device with minimal assistance. Upon discharge, the patient ambulated 250 feet with prosthesis and CG, negotiated one flight of stairs with hand rail and hand held assist, performed basic transfers with CG, and donned device with minimal assistance. Discussion: This case demonstrates the importance of an inter- disciplinary approach to improve the surgery, post-op course, pre- prosthetic and prosthetic training. Conclusions: All disciplines facilitated the transition from a non- functional limb to a household ambulator. Poster 565 Revitalizing an Inefficient, Ineffective Interdisciplinary Team Meeting on a Pediatric Inpatient Rehabilitation Unit. Ashlee Goldsmith, MD (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States). Disclosures: A. Goldsmith, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: Little has been published about best practices for multidisciplinary patient care meetings in an inpatient setting. The International Classification of Function (ICF) inspired the crea- tion of a Team Meeting Communication Checklist. Aims were threefold: increase adherence to checklist content, discuss each patient in the allotted 90 minutes, and increase staff satisfaction with meetings. Design: A multidisciplinary working group was formed to address the perceived dissatisfaction with the current process and aimed for a more efficient and effective team meeting. Literature review identified only one published paper specific to team meetings, which provided a framework for discussion of adult patients with spinal cord injuries based on the ICF functional domain checklist. After revisions, the checklist was unanimously embraced to transform weekly meetings by capturing the desired content and facilitating necessary communication about our patients. Setting: Inpatient pediatric rehabilitation unit. Main Outcome Measures: Baseline data on time, satisfaction, and checklist adherence was collected from 9/2013- 2/2014. Three independent time studies were completed. A 10 question anony- mous staff satisfaction survey was developed. Data were collected S382 PRESENTATIONS
Transcript of Poster 565 Revitalizing an Inefficient, Ineffective Interdisciplinary Team Meeting on a Pediatric...
S382 PRESENTATIONS
Poster 563Neurostimulants as a Treatment for Anoxic BrainInjury in a Two-Year-Old Girl with HereditaryVentricular Arrhythmia: A Case Report.Katarzyna B. Iwan (URMC, Rochester, NY, United States);Denise Norton, MD; Nathan Odom, MD.
Disclosures: K. B. Iwan, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: The patient presented with cardiac arrestsecondary to CPVT/ARVD resulting in anoxic brain injury. She wasinitially sedated to prevent further episodes of ventricular ectopy.Sedation was weaned and diffuse cerebral hypoxia was noted onimaging. Four weeks post cardiac arrest, the patient was initiallytitrated on Nuvigil due to the lower side effect profile and showedimprovement in eye tracking and head control. She was thentransitioned to Provigil and finally Ritalin and regained furtherbrain function. On discharge, the patient continued to makefunctional progress without further episodes of ventricular tachy-cardia while on neurostimulants.Setting: Acute inpatient rehabilitation unit in tertiary carehospital.Results or Clinical Course: At 1 month, 3 months and6 months post administration of neurostimulants, the patientcontinued to regain neurological function. Her therapists havenoted improvements in postural control, balance, motor function,coordination and communication.Discussion: CPVT and ARVD represent a hereditary ventriculartachycardia postulated to cause up to 15% of sudden cardiacdeaths in the pediatric population due to a mutation in voltagegated ion channels. Optimal management of CPVT/ARVD includesinitial sedation to prevent endogenous catecholamine release andventricular ectopy. In contrast, brain injury is managed withneurostimulants which promote cholinergic activity. Moreover,there is no FDA approved neurostimulant dose that can beadministered to patients under six years old. To our knowledge,this is the first reported case of neurostimulant use in a patientunder six years old with hereditary ventricular tachycardia andanoxic brain injury.Conclusions: Neurostimulant use for treatment of brain injuryin children with ventricular arrhythmia is possible despite thecholinergic side effects and no approved pediatric dosing.
Poster 564Knee Disarticulation Followed by AcuteInpatient Rehabilitation Resulting in SignificantFunctional Improvement in a Child with CongenitalFibular Hemimelia and Neurofibromatosis: A CaseReport.GregoryP. Burkard,DO(NYU,Montauk,NY, United States);Dellene E. Troy; Christopher V. Boudakian, DO;Renat Sukhov, MD.
Disclosures: G. P. Burkard, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: The case describes a 5-year-old male whomet most developmental milestones, except was limited to
army style crawling his entire life. Due to psychosocialreasons, the mother opted against an amputation andpreferred a right achilles tendon lengthening at the age of 1for equinovalgus deformity. Despite aggressive outpatientphysical therapy, the patient never gained the ability tofunctionally ambulate, so he was limited to home school forconvenience. The decision was made to undergo a kneedisarticulation and prosthetic fitting to give the boy anopportunity to ambulate.Setting: Pediatric Acute Inpatient Rehabilitation Facility (IRF).Results or Clinical Course: On day of receiving prosthesis, heambulated 30 feet with moderate assistance for advancing pros-thetic and maximum assistance for locking and unlocking knee unitwhile using a rolling walker. He performed basic transfers withcontact guard assistance (CG) and donned device with minimalassistance. Upon discharge, the patient ambulated 250 feet withprosthesis and CG, negotiated one flight of stairs with hand rail andhand held assist, performed basic transfers with CG, and donneddevice with minimal assistance.Discussion: This case demonstrates the importance of an inter-disciplinary approach to improve the surgery, post-op course, pre-prosthetic and prosthetic training.Conclusions: All disciplines facilitated the transition from a non-functional limb to a household ambulator.
Poster 565Revitalizing an Inefficient, IneffectiveInterdisciplinary Team Meeting on a PediatricInpatient Rehabilitation Unit.Ashlee Goldsmith, MD (Cincinnati Children’s HospitalMedical Center, Cincinnati, OH, United States).
Disclosures: A. Goldsmith, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Objective: Little has been published about best practices formultidisciplinary patient care meetings in an inpatient setting. TheInternational Classification of Function (ICF) inspired the crea-tion of a Team Meeting Communication Checklist. Aims werethreefold: increase adherence to checklist content, discuss eachpatient in the allotted 90 minutes, and increase staff satisfactionwith meetings.Design: A multidisciplinary working group was formed toaddress the perceived dissatisfaction with the current process andaimed for a more efficient and effective team meeting. Literaturereview identified only one published paper specific to teammeetings, which provided a framework for discussion of adultpatients with spinal cord injuries based on the ICF functionaldomain checklist. After revisions, the checklist was unanimouslyembraced to transform weekly meetings by capturing the desiredcontent and facilitating necessary communication about ourpatients.Setting: Inpatient pediatric rehabilitation unit.Main Outcome Measures: Baseline data on time, satisfaction,and checklist adherence was collected from 9/2013- 2/2014. Threeindependent time studies were completed. A 10 question anony-mous staff satisfaction survey was developed. Data were collected
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about checklist adherence by team members during meetings.Qualitative interviews were used to compare team membersunderstanding of checklist items prior to implementation. A mockteam meeting was recorded modeling checklist utilization, and anonline educational module was created to train staff members onthe new format.Results or Clinical Course: The baseline satisfaction surveyhad a 77% response rate (24/31 individuals) and weighted averageswere calculated for each question. This survey will be repeated sixweeks after implementation. Time studies will be compared withpost-intervention time data. Checklist adherence data were ob-tained pre-implementation.Conclusions: Overall, this ongoing project will transform thestructure of our weekly team meetings by adhering to a checklistformat, which will hopefully improve satisfaction of team membersand cover 100% of the essential information about each patient inan effective and efficient manner.
Poster 566CLOVES Syndrome Patient Presenting with CaudaEquina and Conus Medullaris Compression:A Case Report.Kwame Asante, m.d (Temple University Hospital,Philadelphia, PA, United States); Phillip Bryant, D.O;Danielle Brant, CRNP.
Disclosures: K. Asante, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: The patient presented with a 2-monthhistory of progressive lower extremity weakness, back pain anda three day history of bowel and bladder incontinence. On exam,he had subtle facial enlargement on the right, a longer and largerright upper and lower limb relative to the left side, port-winemacules on his trunk and extremities, syndactyly of bilateralsecond and third toes, paraparesis, absent patella and achillesreflexes bilaterally and decreased sensation to light touch andpinprick in a sacral dermatomal distribution. MRI of the spinerevealed a Chiari I malformation without syrinx formation, as wellas marked dilatation of vessels in the thoracic and lumbar spinalcanal consistent with an AVM (arteriovenous malformation). TheAVM was noted to compress the conus medullaris and caudaequina.Program Description: A 12-year-old boy with CLOVES(Congenital, Lipomatous Overgrowth, Vascular malformations,Epidermal nevi and Scoliosis/Skeletal/Spinal anomalies) syndrome.Setting: Tertiary care pediatric hospital.Results or Clinical Course: The patient underwent emergentL2-L4 lumbar artery embolization. After embolization, the patientshowed improvement in bowel and bladder control and hadmodest improvement in his lower extremity strength. He subse-quently underwent comprehensive inpatient rehabilitation withprogressive functional improvement in his ambulation and activi-ties of daily living.Discussion: To our knowledge, this is the first reported case ofCLOVES syndrome presenting with cauda equina and conus
medullaris compression. CLOVES syndrome was first recognized asa distinct diagnostic entity in 2007. There have been less than 100cases of CLOVES syndrome reported to date.Conclusions: This case reveals a patient with cauda equina andconus medullaris compression secondary to CLOVES syndromewho showed improvement after embolization and rehabilitationtherapies.
Poster 567Aicardi-Goutie`res syndrome: A Case Report.Shervin Najafi (Montefiore Medical Center/AlbertEinstein College of Medicine , Bronx, NY, United States);Yuxi Chen, MD; Jeffrey Algra, MD MS.
Disclosures: S. Najafi, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: A 4-year-old boy with developmental delay,and lower extremities spasticityProgram Description: This a boy of uncomplicated termvaginal delivery. At 4 months of age, he was found to have headlag and feeding difficulty requiring a G-tube placement. In laterwork-ups, he was noted to have microcephaly, ocular jerkymovements, hypotonia of neck and trunk, forearm skin rashes,spasticity of hip adductors/flexors, hamstrings and gastroc soleusand extreme irritability. He underwent a non-revealing compre-hensive genetic testing and muscle biopsy. His head CT showedbasal ganglia calcifications and brain MRI showed diffuse atrophy.He was diagnosed as cerebral palsy. He underwent surgical hipadductors release and continued his follow-up with pediatricrehab for Botox injection for lower extremity spasticity control,bracing and PT/OT service. At age of 2 year, he developed boutsof fever and seizing during febrile illnesses requiring hospitaladmissions. EEG showed intermittent focal slowing in L temporalregion.Setting: Academic pediatric rehabilitation center.Results or Clinical Course: At age of 3.11, he eventuallywas diagnosed with Aicardi-Goutie`res syndrome (AGS) whichpresents as a rare autosomal recessive disease with early progressiveencephalopathy before 4 months of age, basal ganglia calcifications(hall mark), microcephaly, feeding problem, bouts of mild fever,seizure, trunk hypotonia and extremities hypertonia, and rise ofCSF interferon alpha. Parents were carriers of abnormal gene(RNASEH2A).Discussion: This case indicates AGS presented as atypicalcerebral palsy. It highlights the fact that yet a number of AGSpatients are misdiagnosed because of not-characteristic presen-tations of the disease. It also magnifies the role of new genetictestings and CSF interferon alpha in early diagnosis of suspiciouspatients.Conclusions: AGS is overly misdiagnosed and should betaken into the differential list of patients presenting withstatic or progressive encephalopathy, basal ganglia calcifica-tion, pyramidal and extrapyramidal symptoms, fever andseizure.
