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.

Lenore Jarvis

Screening for postpartum depression in the emergency department

Lenore Jarvis

“Some of these women had no idea how common postpartum depression was,” says Lenore Jarvis, M.D., M.Ed. “They thought they were crazy and felt alone and were bad moms.”

It’s a scenario that Children’s emergency medicine specialist Lenore Jarvis, M.D., M.Ed., has seen countless times: A mother brings her infant to the emergency department (ED) in the middle of the night with a chief complaint of the baby being fussy. Nothing she does can stop the incessant crying, she tells the triage nurse. When doctors examine the baby, they don’t see anything wrong. Often, this finding is reassuring. But, despite their best efforts to comfort her, the mother isn’t reassured and leaves the hospital feeling anxious and overwhelmed.

After these encounters, Dr. Jarvis wondered: Might the mother be the actual patient?

Postpartum depression (PPD) is the most common complication of childbirth, Dr. Jarvis explains, occurring in up to 20 percent of all mothers, and may be higher (up to 50 percent) in low-income and immigrant women. Far beyond simple “baby blues,” the mood disorder can have significant implications for the mother, her baby and the entire family. It can hinder mother-child bonding and lead to early discontinuation of breastfeeding, delayed immunizations, and child abuse and neglect. The associated effects on early brain development might cause cognitive and developmental delays for the infant and, later in life, can manifest as emotional and behavioral problems. PPD can disrupt relationships between parents. And suicide is the top cause of postpartum death.

Mothers are supposed to be screened routinely for PPD at postpartum visits with their maternal or pediatric health care providers. In addition, several medical professional societies – including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists – now recommend screening for PPD in the prenatal and postnatal periods and during routine well-child visits in the outpatient setting. But these screenings often don’t happen, Dr. Jarvis says, either because doctors aren’t following the recommendations or parents aren’t attending these visits due to barriers to health care access or other problems.

One way to sidestep these challenges, she says, is to provide PPD screening in the emergency setting.

“The ED becomes the safety net for people who are not routinely accessing regular checkups for themselves and their children,” Dr. Jarvis says. “If a mother is having an acute crisis in the middle of the night and feeling anxious and depressed, they often come to the emergency department for help.”

Dr. Jarvis and colleagues launched a pilot study in the Children’s ED to screen for PPD. For eight months beginning June 2015, the researchers invited English- and Spanish-speaking mothers who arrived at the ED with infants 6 months old or younger with complaints that didn’t necessitate immediate emergency care to take a short questionnaire on a computer tablet. This questionnaire included the Edinburgh Postnatal Depression Scale, a well-validated tool to screen for PPD, along with basic sociodemographic questions and queries about risk factors that other studies previously identified for PPD.

Just over half agreed to participate. When Dr. Jarvis and colleagues analyzed the results from these 209 mothers, they found that 27 percent scored positive for PPD, more than the average from previous estimates. Fourteen of those mothers reported having suicidal thoughts. Surprisingly, nearly half of participants reported that they’d never been screened previously for PPD, despite standing recommendations for routine screenings at mother and baby care visits, the research team writes in findings published online May 5, 2018, in Pediatric Emergency Care.

Based on the screening results, the researchers implemented a range of interventions. All mothers who participated in the study received an informational booklet from the March of Dimes on PPD. If mothers scored positive, they also received a local PPD resource handout and were offered a consultation with a social worker. Those with a strongly positive score were required to receive a social worker consultation and were given the option of “warm-line” support to PPD community partners, a facilitated connection to providers who offer individual or group therapy or home visits, or to a psychiatrist who might prescribe medication. Mothers with suicidal thoughts were assessed by a physician and assisted by crisis intervention services, if needed.

When the researchers followed up with mothers who screened positive one month later, an overwhelming majority said that screening in the ED was important and that the resources they were given had been key for finding help. Many commented that even the screening process seemed like a helpful intervention.

“Some of these women had no idea how common PPD was. They thought they were crazy and felt alone and were bad moms,” Dr. Jarvis says. “For someone to even ask about PPD made these women aware that this exists, and it’s something people care about.”

Many thanked her and colleagues for the follow-up call, she adds, saying that it felt good to be cared for and checked on weeks later. “It goes to show that putting support systems in place for these new mothers is very important,” she says.

Dr. Jarvis and ED colleagues are currently collaborating with social workers, neonatology and other Children’s National Health System care partners to start screening mothers in the neonatal intensive care unit (NICU) and ED for PPD. They plan to compare results generated by this universal screening to those in their study. These findings will help researchers better understand the prevalence of PPD in mothers with higher triage acuity levels and how general rates of PPD for mothers in the ED and NICU compare with those generated in past studies based on well-child checks. Eventually, she says, they would like to study whether the interventions they prescribed affected the known consequences of PPD, such as breastfeeding,  timely immunization rates and behavior outcomes.

“With appropriate care and resources,” Dr. Jarvis adds, “we’re hoping to improve the lives of these women and their families.”

In addition to Dr. Jarvis, the lead study author, Children’s co-authors include Kristen A. Breslin, M.D., M.P.H.; Gia M. Badolato, M.P.H.; James M. Chamberlain, M.D.; and Monika K. Goyal, M.D., MSCE, the study’s senior author.

Making the grade: Children’s National is nation’s Top 5 children’s hospital

Children’s National rose in rankings to become the nation’s Top 5 children’s hospital according to the 2018-19 Best Children’s Hospitals Honor Roll released June 26, 2018, by U.S. News & World Report. Additionally, for the second straight year, Children’s Neonatology division led by Billie Lou Short, M.D., ranked No. 1 among 50 neonatal intensive care units ranked across the nation.

Children’s National also ranked in the Top 10 in six additional services:

For the eighth year running, Children’s National ranked in all 10 specialty services, which underscores its unwavering commitment to excellence, continuous quality improvement and unmatched pediatric expertise throughout the organization.

“It’s a distinct honor for Children’s physicians, nurses and employees to be recognized as the nation’s Top 5 pediatric hospital. Children’s National provides the nation’s best care for kids and our dedicated physicians, neonatologists, surgeons, neuroscientists and other specialists, nurses and other clinical support teams are the reason why,” says Kurt Newman, M.D., Children’s President and CEO. “All of the Children’s staff is committed to ensuring that our kids and families enjoy the very best health outcomes today and for the rest of their lives.”

The excellence of Children’s care is made possible by our research insights and clinical innovations. In addition to being named to the U.S. News Honor Roll, a distinction awarded to just 10 children’s centers around the nation, Children’s National is a two-time Magnet® designated hospital for excellence in nursing and is a Leapfrog Group Top Hospital. Children’s ranks seventh among pediatric hospitals in funding from the National Institutes of Health, with a combined $40 million in direct and indirect funding, and transfers the latest research insights from the bench to patients’ bedsides.

“The 10 pediatric centers on this year’s Best Children’s Hospitals Honor Roll deliver exceptional care across a range of specialties and deserve to be highlighted,” says Ben Harder, chief of health analysis at U.S. News. “Day after day, these hospitals provide state-of-the-art medical expertise to children with complex conditions. Their U.S. News’ rankings reflect their commitment to providing high-quality care.”

The 12th annual rankings recognize the top 50 pediatric facilities across the U.S. in 10 pediatric specialties: cancer, cardiology and heart surgery, diabetes and endocrinology, gastroenterology and gastrointestinal surgery, neonatology, nephrology, neurology and neurosurgery, orthopedics, pulmonology and urology. Hospitals received points for being ranked in a specialty, and higher-ranking hospitals receive more points. The Best Children’s Hospitals Honor Roll recognizes the 10 hospitals that received the most points overall.

This year’s rankings will be published in the U.S. News & World Report’s “Best Hospitals 2019” guidebook, available for purchase in late September.

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.

inhaler

Keeping kids with asthma out of the hospital

inhaler

Pediatric asthma takes a heavy toll on patients and families alike. Affecting more than 7 million children in the U.S., it’s the most common nonsurgical diagnosis for pediatric hospital admission, with costs of more than $570 million annually. Understanding how to care for these young patients has significantly improved in the last several decades, leading the National Institutes of Health (NIH) to issue evidence-based guidelines on pediatric asthma in 1990. Despite knowing more about this respiratory ailment, overall morbidity – measured by attack rates, pediatric emergency department visits or hospitalizations – has not decreased over the last decade.

“We know how to effectively treat pediatric asthma,” says Kavita Parikh, M.D., M.S.H.S., a pediatric hospitalist at Children’s National Health System. “There’s been a huge investment in terms of quality improvements that’s reflected in how many papers there are about this topic in the literature.”

However, Dr. Parikh notes, most of those quality-improvement papers do not focus on inpatient discharge, a particularly vulnerable time for patients. Up to 40 percent of children who are hospitalized for asthma-related concerns come back through the emergency department within one year. One-quarter of those kids are readmitted.

“It’s clear that we need to do better at keeping kids with asthma out of the hospital. The point at which they’re being discharged might be an effective time to intervene,” Dr. Parikh adds.

To determine which interventions hold promise, Dr. Parikh and colleagues recently performed a systematic review of studies involving quality improvements after inpatient discharge. They published their findings in the May 2018 edition of the journal, Pediatrics. Because May is National Asthma and Allergy Awareness month, she adds, it’s a timely fit.

The researchers combed the literature, looking for research that tested various interventions at the point of discharge for their effect on hospital readmission anywhere from fewer than 30 days after discharge to up to one year later. They specifically searched for papers published from 1991, the year after the NIH issued its original asthma care guidelines, until November 2016.

Their search netted 30 articles that met these criteria. A more thorough review of each of these studies revealed common themes to interventions implemented at discharge:

  • Nine studies focused on standardization of care, such as introducing or revising a specific clinical pathway
  • Nine studies focused on education, such as teaching patients and their families better self-management strategies
  • Five studies focused on tools for discharge planning, such as ensuring kids had medications in-hand at the time of discharge or assigning a case manager to navigate barriers to care and
  • Seven studies looked at the effect of multimodal interventions that combined any of these themes.

When Dr. Parikh and colleagues examined the effects of each type of intervention on hospital readmission, they came to a stunning conclusion: No single category of intervention seemed to have any effect. Only multimodal interventions that combined multiple categories were effective at reducing the risk of readmission between 30 days and one year after initial discharge.

“It’s indicative of what we have personally seen in quality-improvement efforts here at Children’s National,” Dr. Parikh says. “With a complex condition like asthma, it’s difficult for a single change in how this disease is managed to make a big difference. We need complex and multimodal programs to improve pediatric asthma outcomes, particularly when there’s a transfer of care like when patients are discharged and return home.”

One intervention that showed promise in their qualitative analysis of these studies, Dr. Parikh adds, is ensuring patients are discharged with medications in hand—a strategy that also has been examined at Children’s National. In Children’s focus groups, patients and their families have spoken about how having medications with them when they leave the hospital can boost compliance in taking them and avoid difficulties is getting to an outside pharmacy after discharge. Sometimes, they have said, the chaos of returning home can stymie efforts to stay on track with care, despite their best efforts. Anything that can ease that burden may help improve outcomes, Dr. Parikh says.

“We’re going to need to try many different strategies to reduce readmission rates, engaging different stakeholders in the inpatient and outpatient side,” she adds. “There’s a lot of room for improvement.”

In addition to Dr. Parikh, study co-authors include Susan Keller, MLS, MS-HIT, Children’s National; and Shawn Ralston, M.D., M.Sc., Children’s Hospital of Dartmouth-Hitchcock.

Funding for this work was provided by the Agency for Healthcare Research and Quality (AHRQ) under grant K08HS024554. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ.

STAT Madness

Voters select Children’s National innovation as runner-up in national competition

STAT Madness

Facial recognition technology developed and tested by researchers with the Sheikh Zayed Institute for Pediatric Surgical Innovation and Rare Disease Institute at Children’s National was the runner-up in this year’s STAT Madness 2018 competition.

Facial recognition technology developed and tested by researchers with the Sheikh Zayed Institute for Pediatric Surgical Innovation and Rare Disease Institute at Children’s National was the runner up in this year’s STAT Madness 2018 competition. Garnering more than 33,000 overall votes in the bracket-style battle that highlights the best biomedical advances, the Children’s National entry survived five rounds and made it to the championship before falling short of East Carolina University’s overall vote count.

Children’s entry demonstrates the potential widespread utility of digital dysmorphology technology to diverse populations with genetic conditions. The tool enables doctors and clinicians to identify children with genetic conditions earlier by simply taking the child’s photo with a smartphone and having it entered into a global database for computer analyses.

The researchers partnered with the National Institutes of Health National Human Genome Research Institute and clinicians from 20 different countries to acquire pictures from local doctors for the study. Using the facial analysis technology, they compared groups of Caucasians, Africans, Asians and Latin Americans with Down syndrome, 22q11.2 deletion syndrome (also called DiGeorge syndrome) and Noonan syndrome to those without it. Based on more than 125 individual facial features, they were able to correctly identify patients with the condition from each ethnic group with more than a 93 percent accuracy rate. Missed diagnoses of genetic conditions can negatively impact quality of life and lead to premature death.

Children’s National also was among four “Editor’s Pick” finalists, entries that span a diverse range of scientific disciplines. Journalists at the digital publication STAT pored through published journal articles for 64 submissions in the single-elimination contest to honor a select group of entries that were the most creative, novel, and most likely to benefit the biomedical field and the general public.

Each year, 1 million children are born worldwide with a genetic condition that requires immediate attention. Because many of these children experience serious medical complications and go on to suffer from intellectual disability, it is critical that doctors accurately diagnose genetic syndromes as early as possible.

“For years, research groups have viewed facial recognition technology as a potent tool to aid genetic diagnosis. Our project is unique because it offers the expertise of a virtual geneticist to general health care providers located anywhere in the world,” says Marius George Linguraru, D.Phil., M.A., M.S., a Sheikh Zayed Institute for Pediatric Surgical Innovation principal investigator who invented the technology. “Right now, children born in under-resourced regions of the U.S. or the world can wait years to receive an accurate diagnosis due to the lack of specialized genetic expertise in that region.”

In addition to providing patient-specific benefits, Marshall Summar, M.D., director of Children’s Rare Disease Institute that partners in the facial recognition technology research, says the project offers a wider societal benefit.

“Right now, parents can endure a seemingly endless odyssey as they struggle to understand why their child is different from peers,” says Dr. Summar. “A timely genetic diagnosis can dispel that uncertainty and replace it with knowledge that can speed patient triage and deliver timely medical interventions.”

As pediatric use of iNO increased, mortality rates dropped

Smiling-baby-boy

iNO, a colorless odorless gas, is used to treat hypoxic respiratory failure in infants born full-term and near term.

Use of inhaled nitric oxide (iNO) among pediatric patients has increased since 2005 and, during a 10-year time period, mortality rates dropped modestly as the therapeutic approach was applied to a broader range of health ailments, according to an observational analysis presented Feb. 26, 2018, during the 47th Critical Care Congress.

iNO, a colorless odorless gas, is used to treat hypoxic respiratory failure in infants born full-term and near term and also has become an important therapy for acute respiratory distress syndrome and pulmonary hypertension in newborns.

Jonathan Chan, M.D., a Children’s National Health System critical care fellow, analyzed de-identified data from patient visits from January 2005 to December 2015 at 47 children’s hospitals around the nation. Dr. Chan included 18,343 patients in the analysis. Among the findings:

  • As a group, the children had an overall mortality rate of 22.7 percent. The mortality rate dropped from 29.1 percent in 2005 to 21.2 percent in 2015.
  • The median adjusted cost per admission was an estimated $158,740 ($5,846 per patient day).

“This large observational study indicates that the use of iNO grew from 2005 to 2015,” Dr. Chan says. “While hospital stays grew longer during the study period, we saw a decrease in mortality of 0.01 percent per year.”

The highest number of admissions with iNO use included:

Dr. Chan notes that because this is a retrospective observational analysis, the study’s findings should be interpreted as exploratory.

“Off-label use of iNO continues to increase among pediatric patients. And an increasing proportion of admissions are for specialty areas other than neonatal care,” he adds. “Increasing off-label use of iNO is associated with decreased mortality. But it also is associated with an increased length of stay, higher hospital costs and more units of iNO administered.”

47th Critical Care Congress presentation

Monday, Feb. 26, 2018

Human Rhinovirus

Finding the root cause of bronchiolitis symptoms

Human Rhinovirus

A new study shows that steroids might work for rhinovirus but not for respiratory syncytial virus.

Every winter, doctors’ offices and hospital emergency rooms fill with children who have bronchiolitis, an inflammation of the small airways in the lung. It’s responsible for about 130,000 admissions each year. Sometimes these young patients have symptoms reminiscent of a bad cold with a fever, cough and runny nose. Other times, bronchiolitis causes breathing troubles so severe that these children end up in the intensive care unit.

“The reality is that we don’t have anything to treat these patients aside from supportive care, such as intravenous fluids or respiratory support,” says Robert J. Freishtat, M.D., M.P.H., chief of emergency medicine at Children’s National Health System. “That’s really unacceptable because some kids get very, very sick.”

Several years ago, Dr. Freishtat says a clinical trial tested using steroids as a potential treatment for bronchiolitis. The thinking was that these drugs might reduce the inflammation that’s a hallmark of this condition. However, he says, the results weren’t a slam-dunk for steroids: The drugs didn’t seem to improve outcomes any better than a placebo.

But the trial had a critical flaw, he explains. Rather than having one homogenous cause, bronchiolitis is an umbrella term for a set of symptoms that can be caused by a number of different viruses. The most common ones are respiratory syncytial virus (RSV) and rhinovirus, the latter itself being an assortment of more than 100 different but related viruses. By treating bronchiolitis as a single disease, Dr. Freishtat says researchers might be ignoring the subtleties of each virus that influence whether a particular medication is useful.

“By treating all bronchiolitis patients with a single agent, we could be comparing apples with oranges,” he says. “The treatment may be completely different depending on the underlying cause.”

To test this idea, Dr. Freishtat and colleagues examined nasal secretions from 32 infants who had been hospitalized with bronchiolitis from 2011 to 2014 at 17 medical centers across the country that participate in a consortium called the 35th Multicenter Airway Research Collaboration. In half of these patients, lab tests confirmed that their bronchiolitis was caused by RSV; in the other half, the cause was rhinovirus.

From these nasal secretions, the researchers extracted nucleic acids called microRNAs. These molecules regulate the effects of different genes through a variety of different mechanisms, usually resulting in the effects of target genes being silenced. A single microRNA typically targets multiple genes by affecting messenger RNA, a molecule that’s key for producing proteins.

Comparing results between patients with RSV or rhinovirus, the researchers found 386 microRNAs that differed in concentration. Using bioinformatic software, they traced these microRNAs to thousands of messenger RNAs, looking for any interesting clues to important mechanisms of illness that might vary between the two viruses.

Their findings eventually turned up important differences between the two viruses in the NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells) pathway, a protein cascade that’s intimately involved in the inflammatory response and is a target for many types of steroids. Rhinovirus appears to upregulate the expression of many members of this protein family, driving cells to make more of them, and downregulate inhibitors of this cascade. On the other hand, RSV didn’t seem to have much of an effect on this critical pathway.

To see if these effects translated into cells making more inflammatory molecules in this pathway, the researchers searched for various members of this protein cascade in the nasal secretions. They found an increase in two, known as RelA and NFkB2.

Based on these findings, published online Jan. 17, 2018, in Pediatric Research, steroids might work for rhinovirus but not for RSV, notes Dr. Freishtat the study’s senior author.

“We’re pretty close to saying that you’d need to conduct a clinical trial with respect to the virus, rather than the symptoms, to measure any effect from a given drug,” he says.

Future clinical trials might test the arsenal of currently available medicines to see if any has an effect on bronchiolitis caused by either of these two viruses. Further research into the mechanisms of each type of illness also might turn up new targets that researchers could develop new medicines to hit.

“Instead of determining the disease based on symptoms,” he says, “we can eventually treat the root cause.”

Study co-authors include Kohei Hasegawa, study lead author, and Carlos A. Camargo Jr., Massachusetts General Hospital; Marcos Pérez-Losada, The George Washington University School of Medicine and Health Sciences; Claire E. Hoptay, Samuel Epstein and Stephen J. Teach, M.D., M.P.H., Children’s National; Jonathan M. Mansbach, Boston Children’s Hospital; and Pedro A. Piedra, Baylor College of Medicine.

Omar-Ahmed

Child abuse prevention efforts should reach beyond parents

Omar-Ahmed

The findings of a study performed by Omar Z. Ahmed, M.D., should prompt widening the net when attempting to prevent child abuse.

Non-accidental injuries of children by a parent are more common but are likely to be less severe than those caused by a parent’s male partner, a babysitter or a daycare worker, according to a Children’s National study presented during the 2017 American Academy of Pediatrics (AAP) national conference. Based on their findings, the researchers recommend that efforts to prevent child abuse be extended to these additional types of caregivers.

The study performed by Omar Z. Ahmed, M.D., retrospectively reviewed the records of children admitted from 2013 to 2015 to evaluate and treat non-accidental trauma and identified 225 cases of child abuse. The 150 cases for which the perpetrator was identified were included in their analyses. The research team performed multivariate analyses to determine the association between the gender of the alleged perpetrator, the perpetrator’s relationship to the child and the severity of the child’s injuries.

“Among the 150 children hospitalized after suffering non-accidental trauma during the study period, 68.4 percent were injured by a parent; 14 percent were injured by a stepparent, boyfriend or girlfriend; 9.7 percent were injured by a daycare staff member or babysitter; and 4.6 percent were injured by a relative,” says Dr. Ahmed, a research fellow in Children’s Division of Trauma and Burn Surgery. “By far, parents were more likely to be perpetrators of the confirmed or suspected child abuse. However, children injured by a parent’s partner – a group that was overwhelmingly male – were more likely to be more severely injured, to experience severe head injuries and were more likely to require intubation compared with children who were abused by a parent.”

The research team says that the findings should prompt widening the net when attempting to prevent child abuse.

“It confirmed a lot of what we already knew and what was suspected,” Dr. Ahmed says. ”By taking the research a step further – characterizing the severity of injuries and treatments provided within the hospital – we identified caregiver types who are associated with severe child abuse. It gives parents a warning as to what to look out for when children are cared for by other people in the child’s life.”

A next step for the research group: Pre-emptive approaches to target the caregiver groups more likely to place children at risk of injury, he adds. These strategies could include educating caregivers, teaching coping mechanisms and modeling behavior for a wider group of individuals caring for young children, such as how to manage children appropriately when things get difficult, rather than letting anger take over.

“Parents rely on daycare, babysitters and significant others to provide child care while they work; it is not realistic to expect that to change. But we can target these groups for behavior modification in order to decrease the risk of children being injured,” Dr. Ahmed adds.

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.

premature baby in hospital incubator

Improving neonatal intubation training to boost clinical competency

premature baby in hospital incubator

A research team from Children’s National Health System outlined gaps between current simulation training and clinical competency among pediatric residents and then shared recommendations to address them.

Redesigning the mannequins used in medical simulation training could improve residents’ readiness for clinical practice. Presenting at the 2017 American Academy of Pediatrics (AAP) national conference, a research team from Children’s National Health System outlined gaps between current simulation training and clinical competency among pediatric residents and then shared recommendations to address them.

The team noted that the transfer of skill from simulations to clinical encounters does not occur readily. They identified a number of differences between working with a training mannequin and caring for an actual infant: The mannequin’s tongue and head do not move naturally, no fluid lubricates its mouth and throat and, when tilting the head to insert the endotracheal tube, the mannequin’s neck does not flex realistically.

“Current mannequins lack physical and functional fidelity and those shortcomings take a toll on competency as pediatric residents transition from practice simulation sessions to the actual clinic,” says Children’s National Neonatologist Lamia Soghier, M.D., lead author of the poster presented during AAP. “Our work tried to tease out the most important differences between simulating neonatal intubation and actual clinical practice in order to ensure the next generation of mannequins and practice sessions translate to improved clinical competency.”

The study team conducted in-depth interviews with 32 members of the clinical staff, including attending neonatologists and second- and third-year fellows, asking about critical differences in environment, equipment and context as they participated in practice intubations as well as actual intubations in the clinic.

Four key themes emerged, Dr. Soghier and co-authors say:

  • Mannequins’ vocal cords are marked clearly in white, a give-away for trainees tasked with correctly identifying the anatomical feature. In addition, the mannequins are so stiff they need more force when practicing how to position them properly. In the NICU, using that much force could result in trauma.
  • Because current equipment does not simulate color change with a Pedi-Capa non-toxic chemical that changes color in response to exhaled carbon dioxidetrainees can develop poor habits.
  • Training scenarios need to be designed with the learner in mind offering an opportunity to master tasks in a step-by-step fashion, to practice appropriate sedation techniques and for beginners to learn first before being timed.
  • There is a marked mismatch between the feel of a simulated training and the electric urgency of performing the same procedure in the clinic, eroding trainees’ ability to adjust to wildcards in the clinic in real time.

“We carefully design our sessions to provide trainees with the suite of skills they will need to perform well in clinic. Still, there is more we can do inside the hospital and in designing the next generation of mannequins to lead to optimal clinical outcomes,” Dr. Soghier adds. “As a whole, mannequins need to more closely resemble an actual newborn, with flexible vocal cord design in natural colors. The mannequin’s neck should flex with more degrees of freedom. The model’s skin and joints also need to be more flexible, and its head and neck need to move more naturally.”

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.”

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.

Cardiac Intensive Care Unit

Michael Bell to head Division of Critical Care

Cardiac Intensive Care Unit

Michael J. Bell, M.D., will join Children’s National as Chief of the Division of Critical Care Medicine, in April 2017.

Dr. Bell is a nationally known expert in the field of pediatric neurocritical care, and established the pediatric neurocritical care program at the Children’s Hospital of UPMC in Pittsburgh.

He is a founding member of the Pediatric Neurocritical Care Research Group, an international consortia of 40 institutions dedicated to advancing clinical research for children with critical neurological illnesses. Prior to joining the University of Pittsburgh, Dr. Bell served on the faculty at Children’s National and simultaneously conducted research on the impact of inflammation on the developing brain at the National Institute of Neurological Disorders and Stroke (NINDS), within the laboratory of the Chief of the NINDS Stroke Branch.

Dr. Bell also leads the largest study to date evaluating the impact of interventions on the outcomes of infants and children with severe traumatic brain injury (TBI) and analyzing findings to improve clinical practice across the world. The Approaches and Decisions for Acute Pediatric Traumatic Brain Injury (ADAPT) Trial, funded by NINDS, has enrolled 1,000 children through 50 clinical sites across eight countries and compiled an unmatched database, which will be used to develop new guidelines for clinical care and research on TBIs. Dr. Bell is currently working on expanding the scope and continuing the trial for at least the next 5 years.

In his time at Children’s National, he played a critical role in building one of the first clinical pediatric neuro-critical care consult services in the country, which established common protocols between Children’s Divisions of Critical Care Medicine, Neurology, and Neurosurgery aimed at improving clinical care of children with brain injuries. Dr. Bell’s current research interests include: barriers to implementation of traumatic brain injury guidelines, the effect of hypothermia on various brain injuries and applications for neurological markers in a clinical setting.

The Children’s National Division of Critical Care Medicine is a national leader in the care of critically ill and injured infants and children, with clinical outcomes and safety measures among the best in the country across the pediatric, cardiac, and neuro critical care units.

Dr. Kurt Newman and HHS Secretary Price

Kurt Newman: prioritize children in health care

Dr. Kurt Newman and HHS Secretary Price

Children’s National President and CEO Dr. Kurt Newman welcomed Secretary of Health and Human Services Tom Price to the hospital for his first official visit as a member of the Cabinet.

On February 14, Children’s National President and CEO Dr. Kurt Newman met with Secretary of Health and Human Services Tom Price at Children’s National. As part of his first official visit as a member of the Cabinet Dr. Price, who is an orthopaedic surgeon by training, toured our clinics and engaged in open dialogue with patients and families, clinicians, and members of the Children’s National leadership team.

The visit highlighted the excellence of Children’s National care providers and the essential role pediatric hospitals play in helping kids grow up stronger. It was also an opportunity to ensure that children’s health needs are top of mind for a leader who will be central to shaping policies that affect millions of America’s kids.

In their conversations, Dr. Newman emphasized the need for continued investment and dedicated health care infrastructure to support specialized care and research for children – an approach he outlined in detail this week in an op-ed in the Washington Post.

Dr. Newman intends to continue engaging directly with policy leaders and speaking up for children during this pivotal period for the nation’s health care system.

Learn more about advocacy efforts at Children’s National.