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Racial and ethnic disparities in ED opioid prescriptions have decreased

pill bottles and pills

Whereas in 2012, there were clear racial and ethnic differences in opioid prescription rates. By 2019, those differences were no longer statistically significant overall or within sites.

As the provision of opioid prescriptions declined over time, previously marked racial and ethnic disparities in opioid prescription rates at the time of Emergency Department (ED) discharge also attenuated, according to new findings led by Monika Goyal, M.D., M.S.C.E., associate division chief of Emergency Medicine and Trauma Services at Children’s National Hospital, and others.

The research, published in Pediatrics, investigated whether racial and ethnic differences in the delivery of outpatient opioid prescriptions for children discharged from the ED with long-bone fractures diminished over time.

“In 2012 compared to 2019, although rates of opioid prescribing were higher across all racial/ethnic groups, they were highest for NH-white youth,” said Dr. Goyal. “It’s reassuring to see that as rates of opioid prescribing declined over time, such racial and ethnic differences have attenuated.”

Whereas in 2012, there were clear racial and ethnic differences in opioid prescription rates. By 2019, those differences were no longer statistically significant overall or within sites.

However, as clinicians prescribed fewer opioids, sites continued to have moderate racial and ethnic variability in opioid prescribing rates for non-Hispanic white, non-Hispanic Black and Hispanic children.

The authors caution that the reduction of opioid prescription is possibly attributed to the response against the opioid epidemic.  There is also a need for more studies that seek to identify optimal outpatient pain management for children with fractures and ensure suitable post-discharge pain control for all children, regardless of race and/or ethnicity.

The retrospective cross-sectional study sampled children 4-18 years with long bone fractures using the Pediatric Emergency Care Applied Research Network (PECARN) Registry, an electronic health record registry of four geographically diverse pediatric EDs, from January 1, 2012, to December 31, 2019.

Patient race and ethnicity were categorized as non-Hispanic (NH) white, NH-Black, Hispanic or other. The investigators performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and outpatient prescription. Out of the 42,803 ED eligible visits to analyze, 6,441 received an opioid prescription at ED discharge. This data showed that disparities when prescribing an opioid decreased over a 7-year period.

PAS Logo

Children’s National Hospital at the 2021 Pediatric Academic Societies Meeting

Attending the 2021 Pediatric Academic Societies meeting this week? There will be over 20 Children’s National Hospital-affiliated participants at this year’s meeting. We have compiled their sessions into a mini schedule:

Name Program/Department Session and role Date Time
Taeun Chang, M.D.  Neonatal Neurology and Neurocritical Care Program PAS Postgraduate Course: Neonatal Neurology: HIE-focused Project-Based (Chair) Friday, 30 April

 

9:00 AM –
4:00 PM
CT
Taeun Chang, M.D. Neonatal Neurology and Neurocritical Care Program PAS Postgraduate Course: Neonatal Neurology: HIE-focused Project-Based (Presenter) Friday, 30 April 9:30 AM – 10:00 AM
CT
Yuan-Chiao Lu, Ph.D. Developing Brain Research Laboratory Cardiology Poster: Care of the Fetus and Newborn with CHD (Presenter) Saturday, May 1 4:30 PM – 4:45 PM
CT
Chidiogo Anyigbo, M.D., M.P.H. General and Community Pediatrics Poster: Health Services Research I (Presenter)

 

Saturday, May 1 5:15 PM – 5:30 PM
CT
Panagiotis Kratimenos, M.D. Neonatology Platform (moderator) Saturday, May 1 4:30 PM – 6:00 PM
CT
Sudeepta Basu, MBBS, MS Neonatology Hot Topic Symposia: The Neurological Implications of Abnormal Glycemia in Neonatal Encephalopathy and Prematurity (Chair) Sunday, May 2 9:00 AM – 12:00 PM
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Sudeepta Basu, MBBS, MS Neonatology Hot Topic Symposia: The Neurological Implications of Abnormal Glycemia in Neonatal Encephalopathy and Prematurity (Presenter) Sunday, May 2 9:55 AM – 10:15 AM
CT
Ashraf Harahsheh, M.D., F.A.C.C., F.A.A.P.

 

Cardiology Cardiology: Heart Disease in the Older Child Sunday, May 2 10:00 AM – 12:00 PM
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Rana F. Hamdy, M.D., MPH, MSCE Infectious Diseases

 

Expanding Outpatient Antibiotic Stewardship: Practical Strategies, Novel Settings, and Sociobehavioral Influences (Presenter) Sunday, May 2 10:15 AM – 10:30 AM
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Rana F. Hamdy, M.D., MPH, MSCE Infectious Diseases

 

Hot Topic Debates: Antibiotic Use in Hospitalized Children (Chair) Sunday, May 2 1:00 PM – 3:00 PM
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John Idso, M.D. Critical Care Poster: Resuscitation and Potpourri (presenter) Sunday, May 2 2:20 PM – 2:30 PM
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Michael Shoykhet, M.D., Ph.D. Critical Care Medicine

 

Critical Care Poster: Resuscitation and Potpourri (presenter) Sunday, May 2 2:20 PM – 2:30 PM
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Panagiotis Kratimenos, M.D. Neonatology Neonatal Neurology: Basic & Translational I (moderator) Sunday, May 2

 

4:30 PM – 6:00 PM
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Monika Goyal, M.D. Emergency Medicine and Trauma Services Injury Prevention (moderator) Sunday, May 2 10:00 AM – 12:00 PM
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Ioannis Koutroulis, M.D., Ph.D., M.B.A. Genetic Medicine Research

 

Emergency Medicine III (moderator) Tuesday, May 4 2:00 PM – 4:00 PM
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Sudeepta Basu, MBBS, MS Neonatology Neonatal Neurology: Clinical: HIE and Other Insults (moderator) Tuesday, May 4 4:30 PM – 6:00 PM
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Josepheen De Asis-Cruz, M.D., Ph.D. Center for the Developing Brain Neonatal Neurology: Clinical: HIE and Other Insults (presenter) Tuesday, May 4 4:30 PM – 4:45 PM
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Asad Bandealy, M.D., MPH
Priti Bhansali, M.D. Monika Goyal, M.D.
Sabah Iqbal, M.D. Kavita Parikh, M.D. Shilpa Patel, M.D.
Workshop. ThisIsSTILLOurLane: Protect Kids, Not Guns Monday, May 10 9:00 AM – 11:00 AM
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Cara Lichtenstein, M.D. General and Community Pediatrics APA Injury Control/Advocacy Training Combined SIG (SIG Chair) Monday, May 10 1:00 PM – 3:00 PM
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Terry Kind, M.D., MPH General and Community Pediatrics

 

APA Women in Medicine / Qualitative Research Combined SIG (SIG Chair) Wednesday, May 12 9:00 AM – 11:00 AM
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Phase I: April-30-May 4 and Phase II: May 10-June 4

PAS 2021 Virtual Schedule

Little boy going to school with protective mask

Firearm injuries involving young children in the United States during the COVID-19 pandemic

Little boy going to school with protective mask

After seeing the surge of firearm injuries in young children and inflicted by young children during the first six months of the COVID-19 pandemic, the study’s experts are saying there is an urgent and critical need for enactment of interventions aimed at preventing firearm injuries and deaths involving children.

A recent study pre-published in Pediatrics found that the COVID-19 pandemic is associated with a surge in fatal and nonfatal firearm injuries both in young children and inflicted by young children, correlating with a rise in firearm acquisitions.

The findings, led by Children’s National Hospital experts, show the risk was higher during the first six months of the COVID-19 pandemic as compared to the pre-COVID period.

“According to the Centers for Disease Control and Prevention, firearms are a leading cause of injury and death among youth,” said Monika K. Goyal, M.D., M.S.C.E., senior author of this study and associate  chief of Emergency Medicine and Trauma Services at Children’s National. “The pandemic has led to an increase in these preventable tragedies and it is incumbent upon us as a society to put appropriate measures in place to keep children safe.”

“Increased firearm purchases are one reason we have seen an increase in firearm injuries during the pandemic,” said Joanna S. Cohen, M.D., associate professor of Pediatrics and Emergency Medicine. “Increased purchases are likely related to the political unrest we recently witnessed and increased firearm injuries may be related to children being at home more. Whereas children were in school before, they might be home unsupervised while parents and caretakers are working.”

In addition, there has been an increase in domestic violence over the course of the pandemic which, according to Dr. Cohen, could be a reflection of the stress emerging from financial insecurity, joblessness, illness and other stressors deriving from the pandemic.

After seeing the surge of firearm injuries in young children and inflicted by young children during the first six months of the COVID-19 pandemic, the study’s experts are saying there is an urgent and critical need for enactment of interventions aimed at preventing firearm injuries and deaths involving children.

“There is an urgent need for strategies to prevent further injuries,” Dr. Goyal said. “This includes counseling families on firearm safety at home, having more sensible gun laws and educating the public accordingly.”

In the past, if you were a new gun owner, you would have access to training on how to handle a gun and find safe storage. With all the sheltering in place due to the pandemic, those educational opportunities have fallen by the wayside. “Now you have more people who have become new gun owners but haven’t had the opportunity to get education on safe gun ownership, coinciding with more children staying at home because of the pandemic,” Dr. Goyal said.

The increase in domestic violence could also be a contributing factor. Children are often witnesses to violence at home, Dr. Cohen explained. In many cases, she said, if children see a parent being threatened with a gun, they might model that behavior without fully understanding the implications of holding a gun and the injury it can cause.

child reaching into drawer for gun

Sociodemographic factors linked to intentional youth firearm injuries

child reaching into drawer for gun

A new study led by researchers at Children’s National Hospital, finds that sociodemographic factors related to intent of injury by firearm may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

Firearm injuries are a leading and preventable cause of injury and death among youth – responsible for an estimated 5,000 deaths and 22,000 non-fatal injury hospital visits each year in American kids. And while hospital systems are poised to tackle this issue using a public health approach, prevention efforts and policies may be differentially effective. A new study led by researchers at Children’s National Hospital, finds that sociodemographic factors related to intent of injury by firearm may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

“We sought to explore differences by injury intent in a nationally representative sample of youth presenting to the emergency department with firearm injury,” said Shilpa Patel, M.D., M.P.H., emergency medicine physician at Children’s National Hospital. “We are hopeful that hospitals will support programs that are targeted, patient-centered and relevant to their communities to prevent firearm injury among youth.”

In one of the first comparative studies of factors and outcomes associated with intentionality of youth firearm injury in a large nationally representative sample, researchers identified more than 178,200 weighted hospital visits for firearm injuries with data collected from the Nationwide Emergency Department Sample (NEDS) from 2009 through 2016. Dr. Patel and her colleagues identified distinct risk profiles for individuals aged 21 and younger, who arrived at emergency departments with firearm injuries over an 8-year period.

Using NEDS data, researchers found that approximately one third of the injuries were categorized as unintentional, another third as assault and a small proportion as self-harm. The majority of visits were among youth age 18 to 21 years with almost 90% male, and more than 40% publicly insured. Nearly a third were admitted to the hospital and 6% died as a result of their firearm injuries. In addition, the study showed that the likelihood of unintentional injury was higher among children age 12 and younger.

Unintentional firearm injuries were also associated with rural hospital location, southern region, emergency department discharge and extremity injury. Self-harm firearm injuries were associated with older age, higher socioeconomic status, rural hospital location, transfer or death, and brain, back and spinal cord injury.

“These findings provide insight into the overlap between risk factors, outcomes and intentionality of youth firearm injury,” says Dr. Shilpa.  “For hospitals looking to implement programs to reduce youth firearm injury, distinct risk profiles identified in our study align with prior evidence to support the following: screen for firearm access and provide counseling on safe storage targeting families with younger children; screen suicidal patients for access to lethal means, especially those hospitals in rural areas; and screen for firearm access especially among children exposed to violence or at risk for assault presenting to urban hospitals.”

Other researchers who contributed to this study include members of S.A.F.E.R. (Safer through Advocacy, Firearm Education and Research) — a firearm safety advocacy group at Children’s National: Gia M. Badolato, M.P.H., Kavita Parikh, M.D., M.S.H.S., and Monika K. Goyal, M.D., M.S.C.E, all of Children’s National, and Sabah F. Iqbal, M.D., of PM Pediatrics.

 

ambulance

Racial disparities in pediatric deaths related to police intervention

ambulance

Black and Hispanic adolescents are significantly more likely to die from shootings related to police intervention compared to non-Hispanic white adolescents, a recent study shows.

A recent study evaluating the use of force by police against children found that Black and Hispanic adolescents are significantly more likely to die from shootings related to police intervention compared to non-Hispanic white adolescents. The findings, led by Children’s National Hospital researchers and reported online Nov. 24 in Pediatrics, mirror similar racial and ethnic disparities in adults and highlight the need for interventions and policies to mitigate these tragedies.

In recent years, concerns about police use of force — particularly its disproportionate application to people of color — have grown exponentially in the U.S. Between 2003 and 2018, there were 6,512 firearm deaths from police intervention in adults, with non-Hispanic Blacks and Hispanics having significantly higher per population mortality rates than whites. However, it’s been unclear whether similar racial and ethnic disparities exist for adolescents killed by police intervention.

To explore this question, Monika K. Goyal, M.D., M.S.C.E., associate division chief of Emergency Medicine and Trauma Services and director of Academic Affairs and Research at Children’s National, and her colleagues used data from the Centers for Disease Control and Prevention’s Web-Based Injury Statistics Query and Reporting System. This database collects national data from death certificates compiled by the National Center for Health Statistics, including cause of death and race and ethnicity.

The researchers identified all adolescents between the ages of 12 and 17 years of age who died from firearm injuries due to police intervention between 2003 and 2018 within this database. They then compared rates of these deaths across different racial and ethnic populations based on U.S. Census Bureau data.

Dr. Goyal and her colleagues found that during the 16-year study period, 140 adolescents had died from police intervention, and of those, 113 involved firearms. The vast majority — about 93% — were male, with a mean age of about 16 years.

Using census data, the researchers found that the rate of firearm deaths due to police intervention was markedly higher among non-Hispanic Black and Hispanic youth when compared to non-Hispanic white youth. Numbers show that, compared to non-Hispanic white children, non-Hispanic Black children had a six-fold higher risk of death due to legal intervention. Similarly, Hispanic children had a risk of death almost three times higher.

“As the country works to reform policing practices and strives to mitigate disparities in our justice system, it is essential we do not forget the disproportionate impact on children of color,” Dr. Goyal says. “Our study confirms these disparities that are stark and unacceptable.”

Dr. Goyal adds that the study only collected data on adolescents who died, rather than non-fatal shootings, and thus, may underestimate the true toll of disparities in use of firearms against youth due to police intervention. Although the study was not designed to investigate the causes of these disparities, she says, recent events provide evidence of structural racism and bias among law enforcement personnel and in its policies.

Although these numbers are small, Dr. Goyal notes that there’s a potential rippling effect, with the death of each child having wide-ranging impact on an entire community.

“Any death of a child is devastating but when it is due to police violence, it leads to distrust in the system and undermines the primary mission to protect,” she says. “The pattern of stark racial and ethnic disparities only adds to this tragedy, further oppressing and alienating communities of color. It’s important to investigate, identify and correct those policies and personnel that perpetuate and exacerbate these disparities.”

Other researchers who contributed to this study include Gia M. Badolato, M.P.H., Meleah D. Boyle, M.P.H., and Robert McCarter, Sc.D., all of Children’s National; April M. Zeoli of Michigan State University; and William Terrill of Arizona State University.

 

coronavirus

Higher COVID-19 rates seen in minority socioeconomically disadvantaged children

coronavirus

Minority and socioeconomically disadvantaged children have significantly higher rates of COVID-19 infection, a new study led by Children’s National Hospital researchers shows.

Minority and socioeconomically disadvantaged children have significantly higher rates of COVID-19 infection, a new study led by Children’s National Hospital researchers shows. These findings, reported online August 5 in Pediatrics, parallel similar health disparities for the novel coronavirus that have been found in adults, the authors state.

COVID-19, an infection caused by the novel coronavirus SARS-CoV-2 that emerged in late 2019, has infected more than 4.5 million Americans, including tens of thousands of children. Early in the pandemic, studies highlighted significant disparities in the rates of infection in the U.S., with minorities and socioeconomically disadvantaged adults bearing much higher burdens of infection. However, says Monika Goyal, M.D., M.S.C.E, a pediatric emergency medicine specialist and associate division chief in the Division of Emergency Medicine at Children’s National whose research focuses on health disparities, it’s been unclear whether these disproportionate rates of infection also extend to youth.

To investigate this question, she and her colleagues looked to data collected between March 21, 2020, and April 28, 2020, from a drive-through/walk-up COVID-19 testing site affiliated with Children’s National — one of the first exclusively pediatric testing sites for the virus in the U.S. To access this free testing site, funded by philanthropic support, patients between the ages of 0 and 22 years needed to meet specific criteria: mild symptoms and either known exposure, high-risk status, family member with high-risk status or required testing for work. Physicians referred patients through an online portal that collected basic demographic information, reported symptoms and the reason for referral.

When Dr. Goyal and her colleagues analyzed the data from the first 1,000 patients tested at this site, they found that infection rates differed dramatically among different racial and ethnic groups. While about 7% of non-Hispanic white children were positive for COVID-19, about 30% of non-Hispanic Black and 46% of Hispanic children were positive.

“You’re going from about one in 10 non-Hispanic white children to one in three non-Hispanic Black children and one in two Hispanic children. It’s striking,” says Dr. Goyal.

Using data from the American Families Survey, which uses five-year census estimates derived from home address to estimate median family income, the researchers separated the group of 1,000 patients into estimated family income quartiles. They found marked disparities in COVID-19 positivity rates by income levels: while those in the highest quartile had infection rates of about 9%, about 38% of those in the lowest quartile were infected.

There were additional disparities in exposure status, Dr. Goyal adds. Of the 10% of patients who reported known exposure to COVID-19, about 11% of these were non-Hispanic white. However, non-Hispanic Black children were triple this number.

Although these numbers show clear disparities in COVID-19 infection rates, the authors are now trying to understand why these disparities occur and how they can be mitigated.

“Some possible reasons may be socioeconomic factors that increase exposure, differences in access to health care and resources, as well as structural racism,” says Dr. Goyal.

She adds that Children’s National is working to address those factors that might increase risk for COVID-19 infection and poor outcomes by helping to identify unmet needs — such as food and/or housing insecurity — and steer patients toward resources when patients receive their test results.

“As clinicians and researchers at Children’s National, we pride ourselves on not only being a top-tier research institution that provides cutting-edge care to children, but by being a hospital that cares about the community we serve,” says Denice Cora-Bramble, M.D., M.B.A., chief medical officer of Ambulatory and Community Health Services at Children’s National and the research study’s senior author. “There’s still so much work to be done to achieve health equity for children.”

Other Children’s National researchers who contributed to this study include Joelle N. Simpson, M.D.; Meleah D. Boyle, M.P.H, Gia M. Badolato, M.P.H; Meghan Delaney, D.O,. M.P.H.; and Robert McCarter Jr., Sc.D.

Gavel in front of a pistol

Saving children’s lives with stricter gun laws

Gavel in front of a pistol

A new study led by clinician-researchers at Children’s National finds states with stricter gun laws had lower firearm-related deaths among children and adolescents.

A new study led by clinician-researchers at Children’s National in Washington, D.C., shows an apparent benefit to stricter laws regulating firearm access: They can save children’s lives.

The study published online July 15, 2019, in Pediatrics shows that states with stricter gun laws had lower firearm-related deaths among children and adolescents. In addition, state laws that had been in place for more than five years requiring universal background checks for firearm purchases were associated with a 35% lower firearm-related death rate among children.

The authors say the findings underscore the need for robust research to understand the interplay between legislation type and pediatric deaths due to firearm injuries.

The cross-sectional study examined 2011 to 2015 firearm fatality data from the Web-based Injury Statistics Query and Reporting System (WISQARS), de-identified data collected by the Centers for Disease Control and Prevention about fatal injuries in the U.S. The team used the Brady Campaign to Prevent Gun Violence’s gun law scorecards which measure the strength or weakness of state laws, with higher scores designating states with consistently strong firearm laws.

Some 21,241 children aged 21 years and younger died from firearm-related injuries over the five-year study period, or about 4,250 deaths per year.

“Firearm injuries represent the second-leading cause of death for U.S. children. That’s about 10 funerals a day for kids whose untimely deaths could have been prevented,” says Monika K. Goyal, M.D., MSCE, director of research in the Division of Emergency Medicine and Trauma Services at Children’s National and the study’s lead author. “For every 10-point increase in the strictness of firearm legislation, there was a 4% drop in firearm-related mortality rates among children and youth.”

States that had laws in effect for five years or longer requiring universal background checks for firearm purchase had 35% lower rates of death due to firearms in children.

“Our findings demonstrate a powerful association between the strength of firearm legislation and pediatric firearm-related mortality, Dr. Goyal adds. “This association remains strong even after we adjust for rates of firearm ownership and other population variables, such as education level, race/ethnicity and household income.”

Just as a combination of evidence-based public health approaches – including legislation mandating seatbelt use – reduced mortality from motor vehicle crashes (6.1 deaths per 100,000 children in 2015 compared with 9.8 deaths per 100,000 in 2007), the authors contend that a similar strategy could help to inform decision-making to reduce childhood injuries and deaths due to firearms.

In addition to Dr. Goyal, additional study authors include Gia M. Badolato, MPH, coauthor, Shilpa J. Patel, M.D., MPH, coauthor and emergency medicine specialist, Kavita Parikh, M.D., MSHS, coauthor and hospitalist, and Robert McCarter Jr., ScD, coauthor and research section head, design and biostatistics, all of Children’s National; and Sabah F. Iqbal, M.D., PM Pediatrics, coauthor.

pill bottles and pills

Fewer than 60% of young women diagnosed with STIs in emergency departments fill scripts

Fewer than 60% of young women diagnosed with sexually transmitted infections (STIs) in the emergency department fill prescriptions for antimicrobial therapy to treat these conditions, according to a research letter published online May 28, 2019, by JAMA Pediatrics.

Adolescents make up nearly half of the people diagnosed with sexually transmitted infections each year. According to the Centers for Disease Control and Prevention, untreated sexually transmitted diseases in women can cause pelvic inflammatory disease (PID), an infection of the reproductive organs that can complicate getting pregnant in the future.

“We were astonished to find that teenagers’ rates of filling STI prescriptions were so low,” says Monika K. Goyal, M.D., MSCE, assistant chief of Children’s Division of Emergency Medicine and Trauma Services and the study’s senior author. “Our findings demonstrate the imperative need to identify innovative methods to improve treatment adherence for this high-risk population.”

The retrospective cohort study, conducted at two emergency departments affiliated with a large, urban, tertiary care children’s hospital, enrolled adolescents aged 13 to 19 who were prescribed antimicrobial treatment from Jan. 1, 2016, to Dec. 31, 2017, after being diagnosed with PID or testing positive for chlamydia.

Of 696 emergency department visits for diagnosed STIs, 208 teenagers received outpatient prescriptions for antimicrobial treatments. Only 54.1% of those prescriptions were filled.

“Teenagers may face a number of hurdles when it comes to STI treatment, including out-of-pocket cost, access to transportation and confidentiality concerns,” Dr. Goyal adds.

Future studies will attempt to identify barriers to filling prescriptions in order to inform development of targeted interventions based in the emergency department that promote adherence to STI treatment.

In addition to Dr. Goyal, study co-authors include Lead Author, Alexandra Lieberman, BA, The George Washington University School of Medicine & Health Sciences; and co-authors Gia M. Badolato, MPH, and Jennifer Tran, PA-C, MPH, both of Children’s National.

Katie Donnelly

Firearm injuries disproportionately affect African American kids in DC Wards 7 and 8

Katie Donnelly

“Because the majority of patients in our analyses were injured through accidental shootings, this particular risk factor can help to inform policy makers about possible interventions to prevent future firearm injury, disability and death,” says Katie Donnelly, M.D.

Firearm injuries disproportionately impact African American young men living in Washington’s Wards 7 and 8 compared with other city wards, with nearly one-quarter of injuries suffered in the injured child’s home or at a friend’s home, according to a hot spot analysis presented during the Pediatric Academic Societies 2019 Annual Meeting.

“We analyzed the addresses where youths were injured by firearms over a nearly 12-year period and found that about 60 percent of these shootings occurred in Ward 7 or Ward 8, lower socioeconomic neighborhoods when compared with Washington’s six other Wards,” says Monika K. Goyal, M.D., MSCE, assistant chief of Children’s Division of Emergency Medicine and Trauma Services and the study’s senior author. “This granular detail will help to target resources and interventions to more effectively reduce firearm-related injury and death.”

In the retrospective, cross-sectional study, the Children’s research team looked at all children aged 18 and younger who were treated at Children’s National for firearm-related injuries from Jan. 1, 2006, to May 31, 2017. During that time, 122 children injured by firearms in Washington were treated at Children’s National, the only Level 1 pediatric trauma center in the nation’s Capitol:

  • Nearly 64 percent of these firearm-related injuries were accidental
  • The patients’ mean age was 12.9 years old
  • More than 94 percent of patients were African American and
  • Nearly 74 percent were male.

Of all injuries suffered by children, injuries due to firearms carry the highest mortality rates, the study authors write. About 3 percent of patients in Children’s study died from their firearm-related injuries. Among surviving youth:

  • Patients had a mean Injury Severity Score of 5.8. (The score for a “major trauma” is greater than 15.)
  • 54 percent required hospitalization, with a mean hospitalization of three days
  • Nearly 28 percent required surgery, with 14.8 percent transferred directly from the emergency department to the operating room and
  • Nearly 16 percent were admitted to the intensive care unit.

“Regrettably, firearm injuries remain a major public health hazard for our nation’s children and young adults,” adds Katie Donnelly, M.D., emergency medicine specialist and the study’s lead author. “Because the majority of patients in our analyses were injured through accidental shootings, this particular risk factor can help to inform policy makers about possible interventions to prevent future firearm injury, disability and death.”

Pediatric Academic Societies 2019 Annual Meeting poster presentatio

  • “Pediatric firearm-related injuries and outcomes in the District of Columbia.”
    • Monday, April 29, 2019, 5:45 p.m. to 7:30 p.m. (EST)

Katie Donnelly, M.D., emergency medicine specialist and lead author; Shilpa J. Patel, M.D., MPH, emergency medicine specialist and co-author; Gia M. Badolato, co-author; James Jackson, co-author; and Monika K. Goyal, M.D., MSCE, assistant chief of Children’s Division of Emergency Medicine and Trauma Services and senior author.

Other Children’s research related to firearms presented during PAS 2019 includes:

April 27, 8 a.m.: “Protect kids, not guns: What pediatric providers can do to improve firearm safety.” Gabriella Azzarone, Asad Bandealy, M.D.; Priti Bhansali, M.D.; Eric Fleegler; Monika K. Goyal, M.D., MSCE;  Alex Hogan; Sabah Iqbal; Kavita Parikh, M.D.; Shilpa J. Patel, M.D., MPH; Noe Romo; and Alyssa Silver.

April 29, 5:45 p.m.: “Emergency department visits for pediatric firearm-related injury: By intent of injury.” Shilpa J. Patel, M.D., MPH; Gia M. Badolato; Kavita Parikh, M.D.; Sabah Iqbal; and Monika K. Goyal, M.D., MSCE.

April 29, 5:45 p.m.: “Assessing the intentionality of pediatric firearm injuries using ICD codes.” Katie Donnelly, M.D.; Gia M. Badolato; James Chamberlain, M.D.; and Monika K. Goyal, M.D., MSCE.

April 30, 9:45 a.m.: “Defining a research agenda for the field of pediatric firearm injury prevention.” Libby Alpern; Patrick Carter; Rebecca Cunningham, Monika K. Goyal, M.D., MSCE; Fred Rivara; and Eric Sigel.

little boy looking at gun

A ‘compelling call’ for pediatricians to discuss firearm safety

little boy looking at gun

The Children’s commentators point to the “extremely dangerous” combination of “the small curious hands of a young child” and “the easily accessible and operable, loaded handgun” and suggest that pediatricians who counsel families about safely storing weapons tailor messaging to the weapon type and the family’s reason for owning a firearm.

Paradoxically, as overall firearm ownership decreased in U.S. households with young children from 1976 to 2016, the proportion of these families who owned handguns increased. This shift in firearm preferences over decades from mostly rifles to mostly handguns coincided with increasing firearm-mortality rates in young children, researchers report Jan. 28, 2019, in Pediatrics.

“Almost 5 million children live in homes where at least one firearm is stored loaded and unlocked,” Kavita Parikh, M.D., a pediatric hospitalist at Children’s National Health System, and co-authors write in an invited commentary. “This study is a loud and compelling call to action for all pediatricians to start open discussions around firearm ownership with all families and share data on the significant risks associated with unsafe storage. It is an even louder call to firearm manufacturers to step up and innovate, test and design smart handguns, inoperable by young children, to prevent unintentional injury,” Dr. Parikh and colleagues continue.

The Children’s commentators point to the “extremely dangerous” combination of “the small curious hands of a young child” and “the easily accessible and operable, loaded handgun” and suggest that pediatricians who counsel families about safely storing weapons tailor messaging to the weapon type and the family’s reason for owning a firearm.

They also advocate for childproofing firearms stored in the home – through free or discounted locks, storing weapons separately from ammunition, and using personalized technology that limits the firearm’s potential to be used by children accidentally. According to a retrospective, cross-sectional study led by Children’s researchers, younger children are more likely to be shot by accident.

“The development of effective safety controls on firearms is not only attainable but could be the next big step towards reducing mortality, especially among our youngest. We as a society should be advocating for continued research to ‘childproof’ firearms so that if families choose to have firearms in the home, the safety of their children is not compromised,” Dr. Parikh and co-authors write.

In addition to Dr. Parikh, the senior author, the Pediatrics commentary co-authors include Lead Author Shilpa J. Patel M.D., MPH, emergency medicine specialist; and co-author Monika K. Goyal M.D., MSCE, assistant division chief and director of research in Children’s Division of Emergency Medicine.

emergency signs

Disparities in who accesses emergency mental health services

emergency signs

A Children’s research team found the number of children and adolescents visiting the nation’s emergency departments due to mental health concerns continued to rise at an alarming rate from 2012 through 2016, with mental health diagnoses for non-Latino blacks outpacing such diagnoses among youth of other racial/ethnic groups.

The demand for mental health services continues to be high in the U.S., even among children. The Centers for Disease Control and Prevention (CDC) reports that one in seven U.S. children aged 2 to 8 had a diagnosed mental, behavioral or developmental disorder. In addition, 3 percent of U.S. children aged 3 to 17 had a diagnosis of anxiety, and 2.1 were diagnosed with depression, according to the CDC.

Knowing which children use mental health services can help health care providers improve access and provide more targeted interventions.

Children’s researchers recently investigated this question in the emergency room setting, reporting results from their retrospective cross-sectional study at the American Academy of Pediatrics (AAP) 2018 National Conference & Exhibition. The research team found the number of children and adolescents visiting the nation’s emergency departments due to mental health concerns continued to rise at an alarming rate from 2012 through 2016, with mental health diagnoses for non-Latino blacks outpacing such diagnoses among youth of other racial/ethnic groups.

“Access to mental health services among children can be difficult, and data suggest that it can be even more challenging for minority children compared with non-minority youths,” says Monika K. Goyal, M.D., MSCE, assistant division chief and director of research in the Division of Emergency Medicine at Children’s National Health System and the study’s senior author. “Our findings underscore the importance of improving access to outpatient mental health resources as well as expanding capacity within the nation’s emergency departments to respond to this unmet need.”

An estimated 17.1 million U.S. children are affected by a psychiatric disorder, making mental health disorders among the most common pediatric illnesses. Roughly 2 to 5 percent of all emergency department visits by children are related to mental health concerns. The research team hypothesized that within that group, there might be higher numbers of minority children visiting emergency departments seeking mental health services.

To investigate this hypothesis, they examined Pediatric Health Information System data, which aggregates deidentified information from patient encounters at more than 45 children’s hospitals around the nation. Their analyses showed that in 2012, 50.4 emergency department visits per 100,000 children were for mental health-related concerns. By 2016, that figure had grown to 78.5 emergency department visits per 100,000 children.

During that same five-year time span, there were 242,036 visits by children and adolescents 21 and younger with mental health-related issues*. Within that group:

  • The mean age was 13.3
  • Nearly 55 percent were covered by public insurance
  • 78.4 per 100,000 non-Latino black children received mental health-related diagnoses and
  • 51.5 per 100,000 non-Latino white children received mental health-related diagnoses.

“When stratified by race and ethnicity, mental health-related visits to the nation’s emergency departments rose for non-Latino black children and adolescents at almost double the rate seen for non-Latino white children and adolescents,” Dr. Goyal adds. “These children come to our emergency departments in crisis, and across the nation children’s hospitals need to expand mental health resources to better serve these vulnerable patients.”

Because the study did not include reviews of individual charts or interviews with patients or providers, the reason for the disparate demand for mental health resources remains unclear.

*The number of patient visits during the five-year study period was revised on Nov. 1 2018, after updated analyses.

American Academy of Pediatrics National Conference & Exhibition presentation

  • “Racial disparities in pediatric mental health-related emergency department visits: a five-year, multi-institutional study.”

Anna Abrams, M.D.; Gia Badolato, MPH; Robert McCarter Jr., ScD; and Monika K. Goyal, M.D., MSCE

Femoral fracture

Broken system? Pain relief for fractures differs by race/ethnicity

Femoral fracture

Data collected by a multi-institutional research team show that kids’ pain from long bone fractures may be managed differently in the emergency department depending on the child’s race and ethnicity.

Children who experience broken bones universally feel pain. However, a new multi-institutional study presented at the American Academy of Pediatrics (AAP) 2018 National Conference & Exhibition suggests that emergency treatment for this pain among U.S. children is far from equal. Data collected by the research team show that kids’ pain may be managed differently in the emergency department depending on the child’s race and ethnicity. In particular, while non-Latino black children and Latino children are more likely to receive any analgesia, non-white children with fractured bones are less likely to receive opioid pain medications, even when they arrive at the emergency department with similar pain levels.

“We know from previously published research that pain may be treated differentially based on a patient’s race or ethnicity in the emergency department setting. Our prior work has demonstrated that racial and ethnic minorities are less likely to receive opioid analgesia to treat abdominal pain, even when these patients are diagnosed with appendicitis,” says study leader Monika K. Goyal, M.D., MSCE, assistant division chief and director of Academic Affairs and Research in the Division of Emergency Medicine at Children’s National Health System. “Emergency departments delivering evidence-based care should treat all pediatric patients consistently. These findings extend our work by demonstrating that children presenting with long bone fractures also experience differential treatment of pain based on their race or ethnicity.”

The AAP calls appropriately controlling children’s pain and stress “a vital component of emergency medical care” that can affect the child’s overall emergency medical experience. Because fractures of long bones – clavicle, humerus, ulna, radius, femur, tibia, fibula – are commonly managed in the emergency department, the research team tested a hypothesis about disparities in bone fracture pain management.

They conducted a retrospective cohort study of children and adolescents 21 and younger who were diagnosed with a long bone fracture from July 1, 2014, through June 30, 2017. They analyzed deidentified electronic health records stored within the Pediatric Emergency Care Applied Research Network Registry, which collects data from all patient encounters at seven pediatric emergency departments.

During that time, 21,642 patients with long bone fractures met the study inclusion criteria and experienced moderate to severe pain, rating four or higher on a 10-point pain scale. Some 85.1 percent received analgesia of any type; 41.5 percent received opioid analgesia. Of note:

  • When compared with non-Hispanic white children, minority children were more likely to receive pain medication of any kind (i.e. non-Latino black patients were 58 percent more likely to receive any pain medication, and Latino patients were 23 percent more likely to receive any pain medication).
  • When compared with non-Latino white children, minority children were less likely to receive opioid analgesia (i.e., non-Latino black patients were 30 percent less likely to receive opioid analgesia, and Latino patients were 28 percent less likely to receive opioid analgesia).

“Even though minority children with bone fractures were more likely to receive any type of pain medication, it is striking that minority children were less likely to receive opioid analgesia, compared with white non-Latino children,” Dr. Goyal says. “While it’s reassuring that we found no racial or ethnic differences in reduction of patients’ pain scores, it is troubling to see marked differences in how that pain was managed.”

Dr. Goyal and colleagues are planning future research that will examine the factors that inform how and why emergency room physicians prescribe opioid analgesics.

American Academy of Pediatrics National Conference & Exhibition presentation

  • “Racial and ethnic differences in the management of pain among children diagnosed with long bone fractures in pediatric emergency departments.”

Monika K. Goyal, M.D., MSCE, and James M. Chamberlain, M.D., Children’s National; Tiffani J. Johnson, M.D., MSc, Scott Lorch, M.D., MSCE, and Robert Grundmeier, M.D., Children’s Hospital of Philadelphia; Lawrence Cook, Ph.D., Michael Webb, MS, and Cody Olsen, MS, University of Utah School of Medicine; Amy Drendel, DO, MS, Medical College of Wisconsin; Evaline Alessandrini, M.D., MSCE, Cincinnati Children’s Hospital; Lalit Bajaj, M.D., MPH, Denver Children’s Hospital; and Senior Author, Elizabeth Alpern, M.D., MSCE, Lurie Children’s Hospital.

Emergency Department Check in

Missed opportunities for STI screening in the ED

Emergency Department Check in

Researchers found that even though young women with pelvic inflammatory disease (PID) are at increased risk for also being infected with syphilis and human immunodeficiency virus (HIV), few adolescent females diagnosed with PID in U.S. pediatric emergency departments (ED) undergo laboratory tests for HIV or syphilis.

Sexually transmitted infections (STIs) are on the rise in the U.S., reaching unprecedented highs in recent years for the three most common STIs reported in the nation: chlamydia, gonorrhea and syphilis. Nearly half of the 20 million new STI cases each year are in adolescents aged 15 to 24, according to the Department of Health & Human Services. In particular, about two in five sexually active teen girls has an STI.

These infections can be far more than an embarrassing nuisance; some can cause lifelong infertility. According to the Centers for Disease Control and Prevention, undiagnosed STIs cause infertility in more than 20,000 women each year.

A new retrospective cohort study led by researchers at Children’s National Health System and published online July 24, 2018, in Pediatrics shines a stark spotlight on missed opportunities for diagnosis. Researchers found that even though young women with pelvic inflammatory disease (PID) are at increased risk for also being infected with syphilis and human immunodeficiency virus (HIV), few adolescent females diagnosed with PID in U.S. pediatric emergency departments (ED) undergo laboratory tests for HIV or syphilis.

A team of Children’s researchers reviewed de-identified data from the Pediatric Health Information System, a database that aggregates encounter-level data from 48 children’s hospitals across the nation. From 2010 through 2015, there were 10,698 diagnosed cases of PID among young women aged 12 to 21. Although HIV and syphilis screening rates increased over the study period, just 27.7 percent of these women underwent syphilis screening, 22 percent were screened for HIV, and only 18.4 percent underwent lab testing for both HIV and syphilis.

Screening rates varied dramatically by hospital, with some facilities screening just 2 percent of high-risk young women while others tested more than 60 percent.

HIV screening was more likely to occur among:

  • Women admitted to the hospital, compared with those discharged from the ED (adjusted odds ratio [aOR] of 7.0)
  • Uninsured women, compared with women with private insurance (1.6 aOR)
  • Non-Latino African American women, compared with non-Latino white women (1.4 aOR)
  • Women seen at small hospitals with fewer than 300 beds (1.4 aOR)
  • Women with public insurance compared with women with private insurance (1.3 aOR)
  • 12-year-olds to 16-year-olds, compared with older adolescents (1.2 aOR)

Syphilis screening was more likely to occur for:

  • Women admitted to the hospital (4.6 aOR)
  • Non-Latino African American women (1.8 aOR)
  • Uninsured women (1.6 aOR)
  • Women with public insurance (1.4 aOR)
  • 12-year-olds to 16-year-olds (1.1 aOR)

“We know that 20 percent of the nearly 1 million cases of PID that are diagnosed each year occur in young women, with the majority of diagnoses made in EDs. It is encouraging that HIV and syphilis screening rates for women with PID increased over the study period. However, our findings point to missed opportunities to safeguard young women’s reproductive health,” says Monika K. Goyal, M.D., M.S.C.E., assistant professor of Pediatrics and Emergency Medicine and the study’s senior author. “Such discrepancies in screening across the 48 hospitals we studied underscore the need for a standardized approach to sexually transmitted infection (STI) screening.”

Untreated STIs can cause PID, an infection of a woman’s reproductive organs that can complicate her ability to get pregnant and also can cause infertility. Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended that all women diagnosed with PID be tested for HIV. The CDC’s treatment guidelines also recommend screening people at high risk for syphilis.

“Syphilis infection rates have steadily increased each year, and it is now most prevalent among young adults,” Dr. Goyal says. “Future research should examine how STI screening can be improved in emergency departments, especially since adolescents at high risk for STIs often access health care through EDs. We also should explore innovative approaches, including electronic alerts and shared decision-making to boost STI screening rates for young women.”

In addition to Dr. Goyal, Children’s study co-authors include Lead Author, Amanda Jichlinski, M.D.; and co-authors, Gia Badolato, M.P.H., and William Pastor, M.A., M.P.H.

Research reported in this news release was supported by the National Institute of Child Health and Human Development under K23 award number HD070910.

Stricter state firearms laws can save children’s lives

In a new study presented at the Pediatric Academic Societies (PAS) 2018 annual meeting, Children’s researchers find that states with stricter firearm laws have lower rates of firearm-related deaths in children. The same cross-sectional analyses also found that states with laws that mandate universal background checks prior to firearm and ammunition purchases were associated with lower rates of firearm-related mortality in children, compared with states that lack these laws.

“Injuries due to firearms are the nation’s third-leading cause of pediatric death,” says Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine and Trauma Services at Children’s National Health System and lead author of the research paper. “Firearm legislation at the state level varies significantly. Our findings underscore the need for further investigation of which types of state-level firearm legislation most strongly correlate with reduction in pediatric injuries and deaths.”

The research team analyzed data from the 2015 Web-based injury statistics query and reporting system maintained by the Centers for Disease Control and Prevention to measure the association between Brady Gun Law Scores – a scorecard that evaluates how strict firearms legislation and policies are in all 50 states – and state-based rates of firearm-related death among children aged 21 years and younger.

In 2015, 4,528 children died from firearm-related injuries. Eighty-seven percent were male; 44 percent were non-Latino black; their mean age was 18.

State-specific firearm-related mortality rates among children were as low as 0 per 100,000 to as high as 18 per 100,000. Median mortality rates were lower among the 12 states requiring universal background checks for firearm purchase at 3.8 per 100,000 children compared with 5.7 per 100,000 children in states that did not require background checks. Similarly, the five states with this requirement had a lower median mortality rate, 2.3 per 100,000 children, when compared with states that did not require background checks for ammunition purchase, 5.6 per 100,000 children.

“Newtown. Orlando. Las Vegas. Parkland. Those are among the mass shootings that have occurred across the nation in recent years. While these tragedies often are covered heavily by the news media, they represent a subset of overall pediatric injuries and deaths due to firearms. Pediatric firearm-related injuries are a critical public health issue across the U.S.,” Dr. Goyal adds.

“Pediatricians have helped to educate parents about other public health concerns, such as the danger posed by second-hand exposure to tobacco smoke or non-use of seat belts and car seats. In addition to presenting our most recent study results, members of our research group also hosted a workshop at PAS aimed at inspiring pediatric clinicians to similarly tackle this latest public health challenge and to advocate for firearm safety,” she says.

In addition to Dr. Goyal, study co-authors include Gia Badolato; Shilpa Patel, M.D.; Sabah Iqbal; Katie Donnelly, M.D.; and Kavita Parikh, M.D., M.S.H.S.

Monika Goyal

Monika Goyal M.D., M.S.C.E., consultant on $5M NIH grant to reduce pediatric firearm injuries

Monika Goyal

Monika Goyal M.D., M.S.C.E., director of research in Children’s Division of Emergency Medicine and Trauma Services, has been named a consultant on a new $5 million National Institutes of Health research grant that represents the agency’s largest funding commitment in more than two decades to reduce pediatric firearm injuries.

“I am honored that Children’s National Health System is among the 12 universities and health systems around the nation selected to work collaboratively to identify solutions to lower pediatric deaths and injuries due to firearms,” Dr. Goyal says. “This grant will expand the nation’s research capacity on this important subject area and will power the next wave of research to inform policy at the state and national level.”

Dr. Goyal is a member of Children’s firearms research work group which has published or presented at academic meetings on topics that include efforts to reduce pediatric firearm-related injuries and the pivotal role pediatricians can play in reducing the burden of firearm-related injuries among children.

Faculty from Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University, Arizona State University, Brown University, Children’s National Health System, Columbia University, Harvard University, Medical College of Wisconsin, Michigan State University, University of Colorado, University of Michigan, University of Pennsylvania and University of Washington make up the Firearm-Safety Among Children & Teens Consortium (FACTS). The initiative is co-led by Rebecca Cunningham, M.D., and Marc Zimmerman, Ph.D., of the University of Michigan.

In addition to tapping the expertise of scientists and researchers who specialize in criminal justice, emergency medicine, pediatrics, psychology, public health and trauma surgery, FACTS will include a stakeholder group that includes teachers, parent groups, gun owners, firearm safety trainers and law enforcement partners.

The five-year grant will produce a number of deliverables, including:

  • A research agenda for the field of pediatric firearm injury
  • Generating preliminary data through five small pilot projects that focus on topics such as the epidemiology of pediatric firearm injuries and prevention of firearm injuries
  • A data archive on childhood firearm injury
  • Training for the next generation of researchers, including postdoctoral trainees and graduate students

Financial support for this research was provided by the National Institute of Child Health & Human Development under award number R24HD087149.

group of teenagers sitting on a wall

Better PID management for adolescents in the ED

group of teenagers sitting on a wall

Since adolescents account for half of all new sexually transmitted infection (STI) diagnoses, increasing screening rates for STIs in the emergency department could have a tremendous impact.

Emergency departments at U.S. children’s hospitals had low rates of complying with recommended HIV and syphilis screening for at-risk adolescents, though larger hospitals  were more likely to provide such evidence-based care, according to a study led by Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National Health System.

Presented during the 2017 American Academy of Pediatrics (AAP) national conference, the study also found low compliance with CDC recommendations for antibiotic treatment of adolescents diagnosed with pelvic inflammatory disease (PID), a complication of undiagnosed or undertreated sexually transmitted infection that can signal heightened risk for syphilis or HIV.

“Adolescents account for half of all new sexually transmitted infections (STIs) and often view the emergency department (ED) as the primary place to receive health care. If we are able to increase screening rates for sexually transmitted infections in the ED setting, we could have a tremendous impact on the STI epidemic,” Dr. Goyal says.

Although gonorrhea and chlamydia are implicated in most cases of PID, The Centers for Disease Control and Prevention (CDC) recommend that all women diagnosed with PID be screened for HIV and also recommends syphilis screening for all people at high risk for infection. The research team conducted a cross-sectional study using a database that captures details from 48 children’s hospitals to determine how often the CDC’s recommendations are carried out within the nation’s EDs.

The research team combed through records from 2010 to 2015 to identify all ED visits by adolescent women younger than 21 and found 10,698 PID diagnoses. The girls’ mean age was 16.7. Nearly 54 percent were non-Latino black, and 37.8 percent ultimately were hospitalized.

“It is encouraging that testing for other sexually transmitted infections, such as gonorrhea and chlamydia, occurred for more than 80 percent of patients diagnosed with PID. Unfortunately, just 27.7 percent of these young women underwent syphilis screening, and only 22 percent were screened for HIV,” Dr. Goyal says.

Pediatric ED visits and regional firearm laws

A Children’s research team led by Monika Goyal, M.D., M.S.C.E., found that the Northeast region had the most restrictive firearm laws and the lowest overall burden of firearm-related pediatric emergency department visits.

Pediatric emergency department (ED) visits for gun-related injuries were lower in regions with stronger firearm legislation, according to a five-year study led by Children’s National Health System.

Presenting the findings during the 2017 American Academy of Pediatrics (AAP) national conference, the Children’s research team found that the Northeast region had the most restrictive gun laws and the lowest overall burden of firearm-related pediatric ED visits. Firearm-related pediatric ED visits were significantly higher in the West, South and Midwest, according to the study.

“Firearm-related injuries are a leading cause of injury and death among children and represent a significant public health concern,” says Monika Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National and senior study author. “This study provides compelling data that an evidence-based approach to public policy may help to reduce firearm-related injuries among children.”

The research team extracted data from the Nationwide Emergency Department Sample, the nation’s largest such database, and included ED visits from 2009 to 2013 by patients younger than 21. The team excluded emergency visits due to air, pellet, BB or paintball guns because they are not governed by firearm legislation. They used state-level Brady gun law scores to calculate median regional scores as measures of firearm legislation strictness.

During the five years covered by the study, there were 111,839 ED visits for pediatric firearm-related injuries, or 22,368 per year. The mean age of patients with firearm-related injuries was 18 years old. The majority were male. Across all age groups, 62.8 percent of firearm-related ED visits were because of accidental injuries, a statistic that rose to 81.4 percent for children aged 6 to 10. Six percent of patients died from their injuries, and 29.8 percent of injuries were serious enough to prompt hospital admission.

When compared with the low rates of firearm-related ED visits in the Northeast, the odds of children visiting EDs for firearm-related injuries were significantly higher in other U.S. regions, including the West (2.5), the South (1.9) and the Midwest (1.8).

“Regions with higher Brady scores – and, by extension stricter gun laws – had lower rates of ED visits by children and youth,” Dr. Goyal adds. “To our knowledge, this is the first study to characterize the relationship between children’s firearm-related injuries and the rigor of regional firearm legislation.”

The authors note that unlike adults, most children rushed to the Emergency Department overwhelmingly suffered from accidental firearm injuries. This fact underscores the importance of robust research that focuses specifically on children.

“Despite the importance of this topic, there has been a paucity of published research about firearm-related injuries and how they may be prevented. Most existing data have focused on adults; these findings cannot necessarily be extrapolated to children,” Dr. Goyal says.

pill bottles and pills

White children more likely to receive unnecessary antibiotics in ED

Although antibiotics can turn the tide for a variety of illnesses, they are ineffective against those caused by viruses. Despite this well-known fact, doctors often prescribe antibiotics for viral illnesses.

Infections now considered relatively easy to treat, including some forms of diarrhea and pneumonia, were the leading cause of death throughout the developed world until the 20th century. Then, scientists developed what eventually turned into a miracle cure: Antibiotics that could kill or thwart the growth of a broad array of bacterial species.

Although antibiotics can turn the tide for a variety of illnesses, they are ineffective against those caused by viruses. Despite this well-known fact, doctors often prescribe antibiotics for viral illnesses. Taking these drugs unnecessarily can fuel antibiotic resistance, giving rise to bacteria that don’t respond to the drugs that kept them in check in the past.

A new multicenter study shows how prevalent this scenario can be in hospitals’ Emergency Departments. This research, led by Monika K. Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National Health System, shows that non-Latino white children seeking treatment for viral infections in the Emergency Department (ED) are about twice as likely to receive an antibiotic unnecessarily compared with non-Latino black children or Latino children.

These findings, published online Sept. 5, 2017 in Pediatrics, echo similar racial and ethnic differences in treating acute respiratory tract infections in the primary care setting.

“It is encouraging that just 2.6 percent of children treated in pediatric EDs across the nation received antibiotics for viral acute respiratory tract infections since antibiotics are ineffective in treating viral infections,” Dr. Goyal says. “However, it is troubling to see such persistent racial and ethnic differences in how medications are prescribed, in this case in the ED. In addition to providing the best evidence-based care, we also strive to provide equitable care to all patients.”

Acute respiratory tract infections are among the most common reasons children are rushed to the ED for treatment, Dr. Goyal and co-authors write. Overprescribing antibiotics is also rampant for this viral ailment, with antibiotics erroneously prescribed for 13 percent to 75 percent of pediatric patients.

In the retrospective cohort study, the research team pored over deidentified electronic health data for the 2013 calendar year from seven geographically diverse pediatric EDs, capturing 39,445 encounters for these infections that met the study’s inclusion criteria. The patients’ mean age was 3.3 years old. Some 4.3 percent of non-Latino white patients received oral, intravenous or intramuscular antibiotics in the ED or upon discharge, compared with 2.6 percent of Latino patients and 1.9 percent of non-Latino black patients.

“A number of studies have demonstrated disparities with regards to how children of different ethnicities and races are treated in our nation’s pediatric EDs, including frequency of computed tomography scans for minor head trauma, laboratory and radiology tests and pain management. Unfortunately, today’s results provide further evidence of racial and ethnic differences in providing health care in the ED setting,” Dr. Goyal says. “Although, in this case, minority children received evidence-based care, more study is needed to explain why differences in care exist at all.”

At a time of growing antibiotic resistance, the study authors underscored the imperative to decrease excess antibiotic use in kids. Since the 1940s, the nation has relied on antibiotics to contend with diseases such as strep throat. Yet, according to the Centers for Disease Control and Prevention, at least 2 million people in the United States are infected with antibiotic-resistant bacteria each year.

According to the study authors, future research should explore the reasons that underlie racial and ethnic differences in antibiotic prescribing, including ED clinicians eager to appease anxious parents as well as implicit clinical bias. Dr. Goyal recently received a National Institutes of Health grant to further study racial and ethnic differences in how children seeking treatment at hospital EDs are managed.

“It may come down to factors as simple as providers or parents believing that ‘more is better,’ despite the clear public health risks of prescribing children antibiotics unnecessarily,” Dr. Goyal adds. “In this case, an intervention that educates parents and providers about appropriate antibiotic use could help the pediatric patients we care for today as well as in the future.”

Kavita Parikh

Keeping children safe from firearm-related harm

Kavita Parikh

“While this preventable public health crisis occurs in the home, pediatricians who see children in clinic or at hospitals can play a pivotal role in helping to reduce gun violence,” says Kavita Parikh, M.D., M.S.H.S.

A review led by Children’s National Health System researchers presents new insights about pediatric firearm-related injuries. The findings, published May 23, 2017 in Hospital Pediatrics, show that up to 64 percent of U.S. households have firearms, and almost 40 percent of parents erroneously believe that their children are unaware of where weapons are stored. Additionally, about 22 percent of parents wrongly think that their children have never handled household firearms.

According to the Centers for Disease Control and Prevention, firearm-related injuries are leading causes of injury deaths for youths. Younger children are more likely to be victims of unintentional firearm injuries, the majority of which occur in the home. Older adolescents are more likely to suffer from intentional injuries. Homicide by firearm is the second-leading cause of death for 15- to 19-year-olds, and suicide by firearm ranks as the third-most common cause of death for children aged 10 to 19. Estimates suggest that the cost of medical treatment for firearm-related injuries suffered by youths younger than 21 exceeds $330 million.

“While this preventable public health crisis occurs in the home, pediatricians who see children in clinic or at hospitals can play a pivotal role in helping to reduce gun violence,” says Kavita Parikh, M.D., M.S.H.S., associate professor of pediatrics in the Division of Hospitalist Medicine at Children’s National and study lead author. “In the course of providing care, pediatricians can ask patients and their families about children’s access to firearms, can encourage safe storage of firearms in the home and can support research into firearm-related injury prevention.”

The review article provides an overview of the prevalence of pediatric firearm-related injuries around the nation and a summary of legislative efforts and health care-related advocacy efforts to reduce firearm injuries around the nation. It includes research by four Children’s National co-authors who comprise the institution’s newly formed firearm-injury prevention research work group. Alyssa Silver, M.D., Children’s Hospital at Montefiore, is another co-author.

The study team found that about 20,000 children are transported to Emergency Departments each year for firearm-related injuries. Youths aged 12 to 19 make up 90 percent of this total. On average, 20 U.S. children and youths are hospitalized daily for firearm-related injuries. About 50 percent of the children who are hospitalized for firearm-related injuries are discharged with a disability.

The researchers identified regional variations in the percentage of households with firearms, as well as differences in firearm ownership by race and ethnicity. Across a number of surveys, 6 percent to nearly 50 percent of families reported storing firearms safely by using such methods as trigger locks and locked storage containers. There is a mismatch in what parents report — with many saying their child would never touch a firearm – compared with children who tell researchers they handle “hidden” firearms, including by pulling the trigger. One survey of 5,000 fifth-graders and their caregivers living in three metropolitan areas found 18 percent had household firearms. Of this group, African American and Latino households had lower odds of firearm ownership than families of white, non-Latino children. Among these survey respondents, families of white non-Latino children were less likely than families of African American children to use safer strategies for firearm storage.

“While public health interventions have had varying degrees of success in improving firearm safety, the most effective programs have offered families free gun safety devices,” says Monika Goyal M.D., M.S.C.E., assistant professor of pediatrics and emergency medicine at Children’s National and senior study author. “The stark differences in how parents perceive their children would act and the children’s own recollections to researchers underscore the importance of the combination of counseling parents to talk to their children about firearms and instituting safe storage practices for household guns.”

Sabah F. Iqbal, M.D., assistant professor of pediatrics and emergency medicine at Children’s National and study co-author, adds: “Most families are willing to discuss firearm safety with health care providers. It is encouraging that when families receive safety counseling from health care professionals, they store firearms more safely within the home. Pediatricians need to ask children and their families about the presence of firearms in the home. These essential conversations can occur in any medical setting and need to begin before a child begins to walk and explore their own home.”

Screening for access to firearms within the health care setting where youths receive routine care may represent a beneficial strategy, the authors write. A recent survey conducted among 300 adolescents seen in an Emergency Department found that 16 percent reported having a gun in the home and 28 percent said they could access a loaded gun within three hours. About 50 percent of adolescents screened for firearm access said a friend or relative owned a gun.

The study authors also discuss the benefit of “rigorous, well-conducted” research of firearm-related injuries to guide the work of public health agencies, policymakers and pediatricians, as well as supporting state-level laws shown to be effective in preventing firearm injuries, such as universal background checks and firearm identification.

“Rigorous investigations, with the use of validated scoring systems, large comprehensive databases and accurate detailed reporting and surveillance of firearm access and related injury are urgently needed,” Shilpa J. Patel, M.D., M.P.H., assistant professor of pediatrics and emergency medicine at Children’s National, and co-authors conclude. “A collective, data-driven approach to public health is crucial to halt the epidemic of pediatric firearm-related injury.”

Related reading: Pediatric firearm-related injuries in the United States.

Sabah IqbShilpa Patel, Monika Goyal

Stronger firearm laws reduce ED visits

Sabah Iqbl, Shilpa Patel, Monika Goyal

Children’s National researchers Sabah F. Iqbal, M.D., Shilpa J. Patel, M.D., and Monika K. Goyal, M.D., M.S.C.E., found that regions of the United States with the strictest gun laws also have fewer emergency department visits for pediatric firearm-related injuries.

A new study by researchers from Children’s National Health System find that regions of the United States with the strictest gun laws also have the fewest emergency department visits for pediatric firearm-related injuries. The work is among the few studies to evaluate the association between local laws and firearm-related injury to children and youth. The results, presented at the 2017 annual meeting of the Pediatric Academic Societies, could inform policies at the state and regional levels.

“Our results suggest an association between regional gun laws and firearm-related injuries in children,” says Monika K. Goyal, M.D., M.S.C.E., director of research within Children’s Division of Emergency Medicine and senior author of the poster. “Regions with stricter gun laws had lower incidence rates of firearm-related emergency department visits by children.”

Firearm-related injuries are a leading cause of death and disability among children and adolescents in the United States. It is well established that states with more restrictive gun laws have fewer firearm-related fatalities. However, it has been unclear how these laws affect the rates of firearm-related injuries among children.

To investigate this question, Children’s National researchers gathered data from the Nationwide Emergency Department Sample (NEDS), a set of hospital-based emergency department databases created by the federal Agency for Healthcare Research and Quality to aggregate data about emergency department visits across the country. The researchers matched NEDS data from 2009 to 2013 in patients 21 and younger with state-level Brady Gun Law Scores, a measure of the strength of firearm laws, in four geographic regions: The Midwest, Northeast, South and West.

The researchers found that during this five-year study period, there were 111,839 emergency department visits for pediatric firearm-related injuries nationwide, an average of 22,368 per year. The mean age of patients was 18 years, and the vast majority was male. Just over one-third were publicly insured. About 30 percent of these recorded injuries resulted in hospital admission, and about 6 percent resulted in death.

Overall, firearm-related visits to emergency departments remained consistent over time at a rate of 65 per every 100,000 visits until 2013, when they decreased slightly to 51 per 100,000 visits. However, these rates varied significantly by geographic region. The Northeast had the lowest rate at 40 per 100,000 visits. This was followed by the Midwest, West and South at 62, 68 and 71 per 100,000 visits, respectively.

These numbers roughly matched the Brady Gun Law Scores for each region. The Northeast had the highest Brady score at 45, followed by 8, 9 and 9 for the South, West and Midwest.

These findings, the study authors say, suggest that stricter gun laws might lead to fewer fatalities as well as fewer gun-related injuries among children. Future studies about the role of regional gun culture and its impact on firearm legislation at the regional level, they say, is an important next step in advocating for changes to firearm legislation and reducing pediatric firearm-related injuries.

“Future research work should seek to elucidate the association of specific gun laws with the incidence rates of pediatric firearm-related injuries,” says Shilpa Patel, M.D., M.P.H., an assistant professor of pediatrics and emergency medicine at Children’s National and co-author of the poster. “This work also could evaluate how regional differences — such as social gun culture, gun ownership and other factors — contribute to the significant regional variation in firearm legislation.”

The American Academy of Pediatrics, an organization of 66,000 pediatricians, has repeatedly advocated for stricter gun laws, violence prevention programs, research for gun violence prevention and public health surveillance, physician counseling to patients on the health hazards of firearms and mental health access to address exposure to violence.