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Stephen Teach does an asthma exam

Stephen J. Teach, M.D., MPH, inaugural holder of new endowed chair

Stephen Teach does an asthma exam

Stephen J. Teach, M.D., M.P.H., has been named the inaugural Wendy Goldberg Professor in Translational Research in Child Health and Community Partnerships. This professorship comes with an endowed chair at Children’s National Health System.

The prestigious honor is given for the duration of Dr. Teach’s (and future chair holders’) employment at Children’s National. The award’s namesake, Wendy Goldberg, and her husband, Fred T. Goldberg Jr., are among the brightest stars in the constellation of Children’s National supporters, says Dr. Teach, Associate Dean for Pediatric Academic Affairs and Chair of the Department of Pediatrics at The George Washington University School of Medicine & Health Sciences.

In addition to serving on many Children’s boards, in the mid-2000s the Goldbergs made a $250,000 gift that benefited Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC), Dr. Teach’s award-winning program to improve clinical care, empower patients and families, and conduct new research to improve patients’ outcomes.

“In recognition of the anchor aims of Children’s new strategic plan, the Goldbergs wanted this new gift to focus on the intersection of community health and research,” Dr. Teach says. “Thanks to their generosity, my team will work with community partners to use data to drive improvements in population health.”

With the dedicated funding Dr. Teach was able to hire a new staffer, Caitlin Munoz, to help mine electronic health records to create disease-specific registries that include 15,000 children and adolescents – the lion’s share of kids younger than 17 who live in Washington and have asthma.

“For the first time, we will be able to describe in granular detail the near-universe of local children who have this chronic respiratory disease,” he says. “We will be able to describe many of the most clinically meaningful aspects of nearly every child with asthma who lives in D.C., including mean age, gender, ethnicity and mean number visits to the emergency department.”

Such a richly textured database will help identify children who should be prescribed daily controller medications to help them avoid missing school days due to asthma exacerbations, he says. The next pediatric chronic disease they will track via registry will be pediatric obesity via elevated body mass index.

“That, in and of itself, is insightful data. But the enduring impact of this applied research is it will inform our continuous quality-improvement efforts,” he adds.

By querying the registries the team will be able to tell, for example, how Children’s primary care centers rank comparatively by asking such questions as which percentage of kids with asthma actually take the medicines they had been prescribed the year prior.

“Increasingly, clinical research falls into one of two buckets. You can either do better things: That’s discovering new drugs or processes, like our ongoing clinical trial to desensitize kids to asthma allergens. Or, you can do things better. We often know what to do already. We know that guideline-based asthma care works well. We don’t need to prove that again. We just need to do things better by getting this care to the kids who need it. That’s where this line of research/quality improvement comes in: It’s getting people to do things better.”

Stephen Teach

Stephen Teach, M.D., M.P.H., named associate dean at GW School of Medicine and Health Sciences

Stephen Teach

Stephen J. Teach, M.D., M.P.H., chair of the Department of Pediatrics at Children’s National Health System, was named associate dean for Pediatric Academic Affairs at The George Washington University (GW) School of Medicine and Health Sciences.

Dr. Teach is director and principal investigator of Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC), a care, research and advocacy program focused on helping under-resourced and largely minority children who suffer from asthma. He also serves as principal investigator for the Washington site for the Inner City Asthma Consortium, funded by the National Institutes of Health.

At GW, Dr. Teach will play a critical role in supporting and enhancing education and training relationships between the university and Children’s National and will support the academic advancement of Children’s National faculty. Read more.

asthma medication delivery

School’s in for asthma medication adherence

asthma medication delivery

A research team from Children’s National tried to reduce missed doses of daily medications, improve asthma control and tamp down on schoolchildren’s asthma attacks by outsourcing morning delivery of inhaled corticosteroids to the school nurse.

Doctors and researchers have long known that the level of stress patients experience is inversely linked to how adherent they are with taking medications: The higher the stress, the less likely patients are to take doses of their medication correctly, on time or at all. For families of school-aged children, there are few times more stressful than mornings, when parents or caregivers need to get kids ready for their school day, pack everything they need and get them out the door on time.

These stressful mornings, says Stephen J. Teach, M.D., M.P.H., chair of the Department of Pediatrics at Children’s National Health System, can spell danger for children with persistent asthma. This chronic condition is typically treated with nightly and morning doses of inhaled corticosteroids (ICS), medications that decrease lung inflammation to prevent asthma attacks. When children miss a morning dose because their families are too busy, their asthma symptoms can exacerbate, causing them to miss school, be unable to participate in activities like sports or lose sleep at night.

But Dr. Teach and colleagues had a simple idea to bypass the morning struggle for many families: Instead of trying to fit delivery of ICS into an already packed schedule, why not outsource it to the school nurse?

“We thought that if we could have those morning doses administered by these medically trained individuals with great technique and regularity, then maybe we would see some improved outcomes in kids,” Dr. Teach says. “And we did, in a striking way.”

Dr. Teach and colleagues recruited 46 children to participate in a pilot study, published online June 8, 2017 in the Journal of Asthma. To be eligible, these participants had to be in grades kindergarten through eighth in the Washington, D.C. public school system and on Medicaid, demonstrating the type of financial need that can add to the cumulative stress a family already faces. The children were scattered across 18 schools.

“We thought that if we could have those morning doses administered by these medically trained individuals with great technique and regularity, then maybe we would see some improved outcomes in kids,” Dr. Teach says. “And we did, in a striking way.”

Twenty-one of these participants received morning doses of ICS (the intervention group), which the researchers provided to school nurses along with an asthma action plan. The rest (the control group) remained on their prescribed morning and evening doses at home.

After 60 days, the researchers followed up with schools and families. Through electronic records kept by each school, the researchers found that the intervention group received more than 90 percent of their prescribed morning doses—about the same number reported by parents of the control group. However, the two groups demonstrated impressive differences in quality-of-life measures:

  • While about 24 percent of the intervention group missed one or fewer days of school due to asthma during the 60-day trial, about 44 percent of the control group did.
  • About 43 percent of the intervention group reported functional limitations due to their asthma, compared with 74 percent of the control group.
  • The intervention group reported only 1.7 nights with asthma-related sleep loss in the previous two weeks, compared with 4.1 nights in the control group.
  • Additionally, only about one-quarter of the intervention group required adjustments in family life to accommodate their asthma, compared with more than one-half of the control group.

The reasons for these differences aren’t clear, says Dr. Teach. But he and colleagues suggest that they might be due to over-reporting of how many doses were delivered at home in the control group or improper administration of these drugs at home.

Regardless, he says, the results show that this type of school-based intervention was not only feasible for children, school nurses and families, but also led to numerous positive health outcomes for the participants who received it. Based on the results of this study, Dr. Teach and colleagues have started to prescribe school-based administration of morning ICS doses to families interested in receiving them as a new standard of care.

“These data, combined with data from similar studies at other institutions, suggest that school-based therapy is increasingly becoming a very real and proven option for clinicians and families when adherence is a struggle,” he says.

A successful patient-centered asthma study

A study by Stephen Teach, M.D., M.P.H., shows that extensively engaging stakeholders such as parents, families and local service providers in study design can transform a planned research project into a more patient-centered study.

For hundreds of years, scientific and medical research has followed a process that practically all grade-school children learn as the scientific method: Scientists make observations that lead to a question. After developing a hypothesis, the researchers and colleagues — usually other scientists in the same field — test it by gathering data from experiments, making more observations or searching through the existing literature. Once they have an answer, the researchers often publish it in a scientific journal, which can generate new questions among peer scientists and starts the cycle all over again.

While most research is meant to benefit humankind as a whole, non-scientists and people who aren’t research subjects usually aren’t involved much in the process itself. That can be a serious omission, particularly for medical research, says Stephen J. Teach, M.D., M.P.H., chair of the Department of Pediatrics at Children’s National Health System, and Deborah Quint Shelef, M.P.H., C.C.R.P., AE-C., program director at IMPACT DC, a program at Children’s National Health System that helps patients effectively manage asthma.

“Our patients might view research a little differently than we do. They don’t just want general contributions to knowledge, but specific contributions that people can actually use,” Shelef says. “One of our main goals is to have useful research models that can translate into changes that really improve patient care. It’s hard to make this happen without asking people who are affected most what would address their needs.”

That’s why Shelef and Dr. Teach’s most recent study, featured on the cover of the December 2016 issue of The Journal of Allergy and Clinical Immunology, shifts the research paradigm from a scientist-centered model to what they call a stakeholder-centered approach. Rather than develop the study solely with fellow researchers, the research team led by Children’s National relied heavily on guidance from people who would be most impacted by the results.

The study focused on whether an intervention that reduced parental stress could improve asthma outcomes among low-income African American children. To help design their study, the research team looked to several different sources for advice: African American parents of children treated for asthma at Children’s National; local providers of social, medical, legal and educational services; and experts in psychosocial stress, medication adherence and conducting studies among at-risk youth with asthma.

The researchers gave themselves one year to consult multiple times with each stakeholder group before starting to enroll study subjects in May 2015. In the initial planning phases, the research team intended to focus their study on whether reducing parental stress would change how well children stuck to taking their asthma medications. However, that focus quickly changed, says Shelef. “Medication adherence just wasn’t a meaningful goal to most parents,” she explains. “To them, having more symptom-free days was a better gauge of how well an intervention was working for their children.”

The proposed intervention itself also transformed. Rather than focusing on problem-solving, cognitive-reframing and parenting skills — the researchers’ initial ideas — the final intervention would instead teach participants mindfulness, deep breathing, positive thinking, self-care and gratitude — as well as how to use these coping skills with their children. Rather than being staffed by social workers or psychologists, the stakeholders preferred people they felt they could relate to: Community wellness coaches with experience teaching yoga, meditation or other wellness activities in neighborhoods in which they lived.

Several other tweaks significantly changed the study from its early incarnation into the final version that the researchers are currently implementing, says Dr. Teach. “We ended up in a very different place from where we started based on this extensive process of stakeholder engagement,” he says.

Shelef notes that it’s not always feasible to involve stakeholders so heavily or to intensively plan a study for a year before it begins. Keeping all the advisers focused on the study at hand without radically changing the focus was a challenge, she says, and it was an “incredible scramble” in the end to translate all of their feedback into a cohesive product. However, having input from the people who could gain the most from the research results made it all worth it.

“The real benefit to this approach is the richness of the final product,” Shelef says. “Ultimately, this study will show a lot more than if we hadn’t put so much into it at the beginning.”

Study reveals asthma phenotypes in inner-city children

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What’s known

According to the Centers for Disease Control and Prevention, 8.6 percent of children across the nation, or 6.3 million kids, have asthma, a disease characterized by wheezing and coughing associated with airway obstruction, bronchial hyperresponsiveness, and inflammation of the airway. However, children with asthma with low socioeconomic status who live in inner cities experience a disproportionately high burden of illness. While treatment guidelines provide uniformity in managing allergy and allergic inflammation, such approaches may be misdirected when kids have asthma symptoms but lack allergy or allergic inflammation. Knowledge of distinct disease phenotypes can help to improve care.

What’s new

The Asthma Phenotypes in the Inner City study enrolled school-aged kids living in nine U.S. inner cities, including Washington, DC. The research team collected data about their asthma at the beginning of the one-year study and every two months as the kids’ asthma was managed according to accepted guidelines. Phenotypic analysis for 616 of these kids found their asthma clustered into five distinct groups. Cluster “A” was characterized by lower allergy, lower inflammation, and minimal symptoms. Fifteen percent of the kids fit within “A.” Another 15 percent of kids’ asthma fit within Cluster “B.” They had highly symptomatic asthma despite high step-level treatment and relatively low allergy and inflammation. Cluster “C” was distinguished by minimal symptoms, intermediate allergy and inflammation, and mildly impaired pulmonary physiology. Some 24 percent of kids fit within this group. The remaining kids fit within Cluster “D” or “E” and experienced progressively higher asthma and rhinitis symptoms as well as allergy and inflammation.

Questions for future research

Q: How does exposure to allergens, viruses, and irritants like tobacco smoke—taken individually as well as in combination—influence asthma severity and symptoms for these at-risk youths?
Q: What approaches to treatment might result from these studies?

Training developing immune systems to prevent wheezing early in life

Stephen Teach does an asthma exam

Extensively engaging stakeholders such as parents, families and local service providers in the actual study design transformed a planned research project into a more patient-centered study.

For the small number of U.S. children who grow up on working farms, activities such as feeding the cows and clearing spent hay from the barn are little changed from a thousand years ago. Through such close contact with dirt and farm animals, rural kids’ immune systems develop more normally and better distinguish common bacteria from household allergens like dust, molds, pets, and pests. Rates of allergy and asthma continue to be lower in children who grow up in those conditions.

By contrast, rates of asthma have spiked among urban and disadvantaged kids, who have far less exposure to dirt and animals early in life. Today, leading pediatric institutions, such as Children’s National Health System, are “awash in emergency department (ED) visits for asthma” with each ED visit associated with 10 to 15 missed school days annually on a population basis, says Stephen J. Teach, MD, MPH, Director and Principal Investigator of IMPACT DC , a care, research, and advocacy program focused on under-resourced and largely minority children with asthma.

A paradigm-shifting multicenter clinical trial aims to reverse that trend by going old school and safely exposing very young infants to the type of immune system training they would have experienced if they grew up closer to the earth.

The five-year study, named “Oral Bacterial Extracts (ORBEX): Primary Prevention of Asthma and Wheezing in Children,” is funded by a $27 million cooperative agreement grant from the National Heart, Lung, and Blood Institute, which is part of the National Institutes of Health. Children’s National, one of eight participating sites across the nation, will enroll an estimated 150 children in the study and will receive at least $2.5 million of that grant.

“It is currently thought by many, including me, that asthma and allergic diseases are a result of disordered development of the immune system very early in life,” says Dr. Teach, who is also Chair of the Department of Pediatrics at George Washington University. The immune system development process begins to unfold in the last few months of pregnancy and continues through infancy, meaning “the die is cast, we think, at a very young age.”

According to the Centers for Disease Control and Prevention, 8.6 percent of children across the nation have asthma, but in the District of Columbia, a disproportionately higher number of children suffer from the respiratory ailment. Once children experience early wheezing, changes begin to occur in the architecture of their lungs, causing a thicker basement membrane, a thickening of the lining of the lungs, and resulting in a heightened tendency for the airways in the lungs to become inflamed and to excrete more mucous. As a result, the children’s poorly trained immune system becomes hyper vigilant, ready to recognize a multitude of things as potentially allergenic.

“We’ve got to do something to change the course of the disease and to make it less common and less severe,” Dr. Teach says.

The study will identify 1,000 babies who range in age from 6 months to 18 months who are the highest risk for asthma, either through family history, being diagnosed with eczema, or both. The infants will receive safe doses of the inactivated bacteria, which is marketed under the name Broncho-Vaxom®. The therapy comes in capsule form, which for two years will be sprinkled into bottles or onto food. The children will be followed to gauge whether infants randomly assigned to receive treatment suffer fewer respiratory symptoms than infants randomly assigned to receive placebo.

“The rationale if we can expose these very young children to the benefits, but not the risks, of early life bacterial exposure, they may reap the benefits of developing a more properly functioning and less allergic immune system,” Dr. Teach says.

He says the Children’s National research team has had “remarkable success” engaging young children and their parents in such long-term studies, losing few to attrition.

“Going for five years will be breaking new ground. But all of our experience suggests that we will succeed if we show the families we care, we stay in touch with them, and we form these therapeutic partnerships by saying: ‘We want to partner with you. We can do this safely with mutual benefit.’ Families will get on board,” he says.

Related resources: Learn more about the clinical trial | Research at a Glance