Evidence-Based Approaches to Pediatric and Obstetric Care - Professional Day 2019

1. Professional Day 2019: Evidence-Based Approaches to Care in Pediatrics and Obstetrics Provided by Texas Children’s Hospital September 19th, 2019 | Houston, TX | 8:00 CONTINUING NURSING PROFESSIONAL DEV ELOPMENT Texas Children's Hospital is an approved provider with commendation of continuing nursing education by the Texas Nurses Association - Approver, an accredited approver with distinction, by the American Nurses Credentialing Center’s Commission on Accreditation. REQUIREMENTS FOR SUCCESSFUL COMPLETION To receive contact hours for this continuing education activity, the participant must: • Sign in to the activity • Attend at least one session (contact hours awarded based on attendance) • Complete the post evaluation Once successful completion has been verified, a “Certificate of Successful Completion” will be awarded for up to 8.0 contact hours. For web link issues, email cne@texaschildrens.org CONTINUING MEDICAL EDUCATION (CME) ACCREDITATION Texas Children’s Hospital (TCH) is accredited by the Texas Medical Association to provide continuing medical education for physicians. CREDIT DESIGNATION Texas Children’s Hospital designates this live activity for a maximum of 8.0 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CME transcripts available upon request via email: cme@texaschildrens.org LEARNING OUTCOME: At the completion of this activity the learner will be able to enhance quality care and patient outcomes through evidence-based inter-professional practice in the area of pediatrics and obstetrics. CONFLICTS OF INTEREST The planning committee members/content reviewers and/or presenters of this CME/CNE activity have disclosed NO relevant financial relationships related to the planning or implementation of this CME/CNE activity: Eric Williams, MD, Amanda Garey, Angie Rangel, Deborah Lee, Jessica Ramirez, Jill Stonesifer, Kathryn Holl, Lauren Ivanhoe, and Lindsey Zaremba The following speakers of this CME/CNE activity have disclosed the following relevant financial relationships related to this CME/CNE activity. Those conflicts of interest have been appropriately resolved: • Carla Giannoni, MD – Formal Advisor, EPIC Pediatric Otolaryngology Steer Board • Jeff Wagner – Formal Advisor, Omnicell Advisory Board The activity’s director/Nurse Planner has determined that no one who has the ability to control the content of this CME/CNE activity – planning committee members and presenters/authors/content reviewers – has a conflict of interest.

2. Pet Peeves: Diseases from pets to people Ankhi Dutta, MD, MPH Lisa (Beth) Pali, BSN, RN, CPN

3. No disclosures

4. Identify the major pathogens transmitted from different pets (domestic and wild) to human 2) Discuss the clinical features associated with diseases transmitted from pets 3) Formulate a diagnostic and treatment plan for diseases transmitted from pets 4) Describe prevention strategies in order to keep pets disease free and prevent transmission to human. Goals and objectives:

5. Pets and US

6. Pet STATISTICS 68% of U.S. households own a pet, according to the 2017-2018 National Pet Owners survey (up from 56% in 1988) TOTAL NUMBER OF PETS OWNED IN THE UNITED STATES, BY TYPE OF ANIMAL (millions) Pet Number Freshwater fish 139.3 Cat 94.2 Dog 89.7 Bird 20.3 Saltwater fish 18.8 Small animal 14.0 Reptile 9.4 Horse 7.6 Source: American Pet Products Association's 2017-2018 National Pet Owners Survey.

7. TOTAL U.S. PET INDUSTRY EXPENDITURES, 2007-2017 (1) ($ billions) Yearly Expenditure 2007 41.2 2008 43.2 2009 45.5 2010 48.4 2011 51.0 2012 53.3 2013 55.7 2014 58.0 2015 60.3 2016 66.8 201769.4 (1) Includes food, supplies and over-the-counter medicine, veterinarian care, live animal purchases and grooming and boarding.(2) Estimate.

8. 7 year old boy, enjoys playing outside. They don’t have pets but they have noticed stray dogs and cats in the neighborhood along with opossums and rats on the street in the evenings. He began complaining of myalgia, abdominal pain, nausea and vomiting and has recently developed fever and a rash that began on his trunk and is now spreading to his extremities. What disease do you suspect? Murine typhus: caused by Rickettsia typhi Infected flea feces are rubbed into cuts or scrapes in the skin Human Ehrlichiosis: causes by tick bites (lone star tick)

9. 13 year old female, who has recently developed blisters around her mouth, fever, headache, diarrhea and joint pain. She loves for her dog to give her kisses on her face and mouth. Blood culture growing GNR. • Capnocytophagacanimorsus • Skin lesions to septic shock • Risk factors for severe disease: immunocompromised, asplenic, alcohol use

11. 16 year old male who had been wading through flood waters volunteering with evacuation efforts during and after Hurricane Harvey. Approximately 2 weeks after his time spent volunteering he developed a fever, headache, conjunctival suffusion, severe myalgias of the calf/back, vomiting, diarrhea, skin rash. Now his eyes seem yellow. • Leptospirosis- Leptospirainterrogans • urine-contaminated water and soil • rats, dogs, and livestock (cattle, pigs)

12. 5 year old female comes in to your office. Her best best friend is a miniature Yorkshire terrier “Sparky.” Her mother has noticed fleas on the dog in the past but has chosen not to treat the fleas. Kate recently became frightened when she noticed “rice” in her stool. • DipylidiumCaninum • Infected flea • Treat both the dog and the child with praziquantal

13. 2 yr old presents to your office with high eosinophils and anemia on their routine CBC. Per mother, she has had intermittent abdominal pain and fevers for the past month. They recently rescued two puppies and two kittens. • Toxocara canis and Toxocara cati

14. 18 month old female comes to your office with watery diarrhea, abdominal pain and fever for the past 3 days. Mom has been giving her probiotics. They have 2 puppies at home. Chickens in their backyard and just got a new turkey! She also visited a petting zoo. What is the most likely bacteria? • Multiple possibilities: Campylobacter, Salmonella, E.coli , Yersinia enterocolitica • Parasites

15. COMMON INFECTIOUS Diarrhea from PETS

16. 16 year old female, who volunteers at an animal shelter with kittens develops an enlarged, tender, axillary lymph node with fever, headache, poor appetite and exhaustion about 2-3 weeks after she began volunteering. She has been on Augmentin for the past week without improvement in symptoms. • Bartonellahenselae: Cat Scratch disease

17. 12 year old, has 3 cats at home and is responsible for cleaning the litter box. He has noticed enlarged cervical lymph nodes, fever, fatigue and cough. Also seeing “floaters” with slightly blurry vision. • Toxoplasmosis: Toxoplasma gondii • Cats, unpasteurized goat milk, undercooked meat

18. A cat bit 4 yr old child on the right arm while visiting his grandmother recently. Over the past few days his father noticed the bite becoming red, painful, swollen and has also noticed enlarged lymph nodes in his right axilla. What organisms should you cover for empirically? • Pasteurellamultocida • 70-90% cats and 25-50% dogs are colonizes in their upper respiratory tract

19. A drum-maker from New York City got sick while on tour with a dance troupe in Pennsylvania. He had just returned from Africa with four goat skins that he planned to use to make drums. He said that when he processed the goat skins to remove the hair, he did not use chemicals on the skins to kill germs or wear protection while handing the skins. He also reported that while he processed the skins, hair and dust particles floated into the air. Four days after he last had contact with the goat skins, he began having breathing problems and was hospitalized. In ancient times– this was called the “fifth plague” • Anthrax: Bacillus anthracis • carcasses, hides, hair, wool, meat, and bone meal

20. A 4 yr old boy is admitted to the hospital with fever for the past 12 days, headaches, bodyaches. PE reveal cervical LN+, hepatosplenomegaly. He recently visited his grandmother who lives on a farm and drank “fresh” milk from the cow . Blood culture + for gram negative coccobacilli. • Brucellosis: Caused by Brucella abortus, B.melitensis

21. 16 yr old male who has been working in the farm during spring break presents to the ER with fever, chills, dry cough, fatigue for the past 6 days. He looks ill, tachycardic and tachypneic. He has assisted with birthing of a calf and has been handling sheep as well. • Q fever: Coxiellaburnetii

22. 10 yr old male with dry hacking cough for the past 3 weeks. Fatigued, low grade fevers. You get a CXR and see a BL lower lobe interstitial pneumonia. You ask about pets and dad says they did buy new pets recently about a week prior to his symptoms. What pets do you think he bought? • Birds: any birds, most commonly parakeets, macaws, parrots, cockatoo • Chlamydia psittaci • Exposure to bird /bat guano: Histoplasmosis

24. A 4 year old boy gets admitted to the hospital with fever and left leg pain. Found to have blood culture positive for a gram negative bacteria and MRI showing left tibial osteomyelitis. He is otherwise healthy and has not travelled anywhere else. They just got a new pet! • Reptiles and amphibians! pet turtles, iguanas, geckos, bearded dragons, lizards, snakes, frogs, toads, newts, salamanders • Non-typhoidalSalmonella

26. A 10 yr old girl received a fish tank for her birthday! She has been diligently cleaning the tank as instructed and developed this lesion on her hand. • Mycobacteriummarinum: swimming pool granuloma, fish tank granuloma

27. A 18 month old got bit by a pet rat 2-3 days ago and now presents with fever to 103 with chills, myalgias, maculopapular rash diffusely including palms and soles. The area of the bite looks ulcerated. What would treat this child with? • Penicillin- G • Rat bite fever caused by Streptobacillusmoniliformis or Spirillum minus

28. 10 yr boy recently returned from a trip to Colorado and developed fever, shortness of breath, left sided lymph node swelling which is very painful. He also has some ulcerative skin lesions. In Colorado, he has been handling rabbits in the farm and helped his GF mow the farm. • Tularemia: Francisellatularensis

29. Which famous celebrity has this animal as pet? • What disease can this pet cause? Racoonroundworm:Baylisascarisprocyonis Rabies: Rabies virus (Lyssa virus) Bats, raccoons, skunks, foxes, coyotes, bobcats, and mongoose

30. Rabies • The virus is present in saliva and is transmitted by bites or, rarely, by contamination of mucosa or skin lesions by saliva • Worldwide, most rabies cases in humans result from dog bites • Any warm blooded animal can be infected with rabies virus

31. This disease spread in the 1330s along the great trade routes to Constantinople and then to Europe, where it claimed an estimated 60% of the European population • Plague: Black death • Caused by Yersinia pestis • Rodents, cats, dogs, ground squirrels, prairie dogs and their fleas

32. Prevention • Choose the right pet: caution in children < 5 years, elderly, immunosuppressed, pregnant women • Keep your pet healthy: vaccines, regular vet visits • Practice good hygiene: wash hands, scoop the poop • Play safely: don’t kiss your pet, do not let them lick your face, avoid bites and scratches, always supervise kids around pets

33. Wild animals or exotic animals are not meant to be kept as pets, use extreme caution around these animals • In case of scratch or bite by any animals: Immediately wash the wound with plenty of soap and water, and see a doctor as soon as possible. Consult animal control

34. References • www.cdc.gov • Red Book online