Browsing by Author "Farbo, David"
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Item Barriers to Attendance of Pediatric Patients to the Nephrology Clinic: a Single Center Study(2024-03-21) Tharakan, Liza; Mok, Madison; Razzouk, Randa; Farbo, DavidPurpose: No-shows are defined as when a patient does not attend their scheduled clinic appointment without prior notification. Studies have been conducted in other specialties to show the effect of no-shows on patient and clinic outcomes, however there is limited research surrounding non-attendance in the pediatric nephrology population. Kidney conditions not diagnosed promptly can lead to serious complications including kidney failure and the need for dialysis. Therefore, it is imperative patients attend appointments so these conditions can be properly diagnosed and treated. Our study aimed to identify barriers to attendance of these appointments in the pediatric nephrology population at Cook Children’s Medical Center. This quality improvement project will promote future research into other barriers as well as interventions to improve attendance to nephrology clinics. Methods: A retrospective chart review of pediatric nephrology patients referred to Cook Children’s outpatient nephrology clinics from August 1, 2018 to June 30, 2023 was conducted. Data collection was limited to: patients between 0-21 years old at time of missed appointment, new or established patients with at least one documented no-show, and patients who canceled and did not reschedule. Demographic data was collected from each patient. Data analysis composed of descriptive statistics and frequencies of independent variables. Study data was managed using REDCap (Research Electronic Data Capture) tools hosted at Cook Children’s. Results: Our study found significant associations between no-show/cancellation rates and certain variables. Males were 1.1 times more likely to no-show and cancel. Black/African-American patients were more likely to no-show and cancel than expected. Patients on public insurance were 1.6 times more likely to no-show. Patients older than 12 were more likely to no-show. Patients whose primary language was English were less likely to cancel. Established patients were 1.1 times more likely to cancel. Telemedicine patients were 1.5 times more likely to no-show and 1.4 times more likely to cancel. Conclusion: Our results echo similar studies in other specialties. Socioeconomic disparities and specific diagnoses may be an explanation for increased no-show/cancellation rates in certain groups. Addressing these inequities with interventions designed to ease patient accessibility can improve rates of retention and follow-up. Further studies are necessary to qualify our data and evaluate the effects of implementation measures.Item Retrospective chart review of children on Low-Dose Naltrexone(2024-03-21) Sadaf, Saad; Shams-ul-hooda, Akeil; Brooks, Meredith; Farbo, David; Campbell, Throy; Reyes, Kristy; Gandhi, ArteePurpose Low-dose naltrexone (LDN) is an opioid receptor antagonist that has shown beneficial effects for chronic pain management in adults. ‘Low dose’ refers to doses between 0.1 and 5 mg that have shown anti-inflammatory and antinociceptive effects (Parkitny & Younger, 2017). LDN targets toll-like receptor 4 (TLR4) on microglial cells, which cause nervous system inflammation through activating factors such as cytokines, interleukin (IL) 6, and tumor necrosis factor (TNF) (Younger et al., 2014). However, LDN usage remains unexplored in pediatric chronic pain. This is significant because between 15-35% of youth experience pain-related conditions such as abdominal pain and migraine, on top of other chronic pain conditions (Stancil et al., 2021; King et al., 2011). This study is the first to investigate the effects of LDN in a large cohort of children with chronic pain. Methods A retrospective chart review was conducted on a pediatric outpatient group at Cook Children’s Medical Center that received only LDN between January 2019 and June 2022. Functional disability inventory (FDI) and pain scores were analyzed at the initial and ‘best’ visit, i.e. the lowest FDI/pain score. The FDI is a 15-item questionnaire that measures limitations in children’s physical and psychosocial functioning. These questions include the patient’s ability to walk up the stairs, eat regular meals, and doing athletic activities. 284 total patients were prescribed LDN. Of these, 253 were excluded: 6 (2.3%) patients were prescribed LDN before March 1, 2018, 8 (3.1%) patients never started LDN, 86 (30.2%) patients had no follow-up data in the pain medicine clinic, and 153 (53.8%) patients were prescribed another medication in addition to LDN. In total, 31 patients were prescribed LDN and no other medications. Of those 31 patients, 25 had FDI scores and 23 had data for pain. Patients started LDN at an average age of 15.1 and ended LDN at an average age of 16.4. For FDI and pain scores, a Wilcoxon ranked sum test was performed since the data was ordinal and not normally distributed. IRB approval was obtained. Results Wilcoxon ranked sum test indicated FDI scores did significantly decrease from first (M=22.5) to best (M=16.4) (p<0.003). In contrast, the test did not reveal any significant differences between first (M=4.00) and best (M=3.52) pain scores (p<0.2). Conclusion The findings suggest that LDN may improve pain-related disability in pediatric patients, ultimately improving pain levels and psychosocial function. This also implies that LDN improves the daily functioning of children and allows them to complete routine tasks more efficiently. Results should be interpreted cautiously due to the retrospective study design and limited number of LDN-only cases available to review at this time. Additional prospective research should include whether LDN effects vary with age, or if certain diagnoses are more effectively treated with this medication.Item The Role of ECMO Cannulation on Pediatric Mortality(2024-03-21) Mohiuddin, Enaya; Mowrer, Colin; Hollinger, Laura; Scott, Brianna; Farbo, DavidPurpose: Pediatric oncology, hemophagocytic histiocytosis (HLH), and bone marrow transplant (BMT) patients have variable degrees of underlying immune system suppression and/or dysregulation, putting them at high risk of developing serious illness and potentially requiring extracorporeal life support. Once supported by extracorporeal membrane oxygenation (ECMO), these patients are thought to have a higher mortality when compared to pediatric patients without these conditions. This study aims to describe specific approaches to ECMO support in this population, describing how these patients are cannulated, and how cannulae configuration potentially relates to outcomes. Methods: Retrospective data was collected from multiple institutions, identifying 176 pediatric patients with an oncologic, HLH, and/or BMT diagnosis who were supported by ECMO from 2010. This study evaluates pre-, on and post- ECMO characteristics including oncologic, HLH, and BMT diagnosis, status (active vs remission), reasons for ECMO, the type of ECMO, complications associated with ECMO support, and mortality. Results: Patients supported with veno-venous (VV) ECMO had the highest ECMO, ICU, and hospital survival compared to those supported with, or converted to, veno-arterial (VA) ECMO. Specifically, 67% of VV ECMO patients survived, while 53% of VA neck and 48% of VA femoral ECMO patients survived. Bleeding complications were high in all patients supported with ECMO. Intracranial hemorrhages occurred more frequently in patients with VA neck cannulation compared to femoral approaches, but even in patients on VV support without carotid cannulation, intra-cranial hemorrhage rates were high. Specifically, 27% of VA neck cannulated patients experienced a head bleed during ECMO, while 7% of VA femoral patients and 8% of VV ECMO patients did. Furthermore, 26% of VV ECMO patients required anticoagulation administration 48 hours prior to ECMO, while 94% of patients required anticoagulation during ECMO. 14% of VA neck cannulated patients and 10% of VA femoral cannulated patients required anticoagulation 48 hours prior to ECMO. However, 94% of VA neck cannulated patients and 86% of VA femoral cannulated patients required anticoagulation administration during ECMO. Lastly, femoral cannulation approaches resulted in limb ischemia with increased frequency. Conclusions: Pediatric patients requiring ECMO support during oncological processes require a variety of different cannulation strategies, each with their own associated risks. Overall patient morbidity including major bleeding events and ECMO complication rates are higher than can be expected compared to the average pediatric cohort.