Critical Medicine

BPA analogues may be less likely to disrupt heart rhythm

Some chemical alternatives to plastic bisphenol-a (BPA), which is still commonly used in medical settings such as operating rooms and intensive care units, may be less disruptive to heart electrical function than BPA,

A poster at the AHA Scientific Sessions suggests bisphenol-s (BPS) and bisphenol-f (BPF) may have less impact on heart function than bisphenol-a (BPA).

Some chemical alternatives to plastic bisphenol-a (BPA), which is still commonly used in medical settings such as operating rooms and intensive care units, may be less disruptive to heart electrical function than BPA, according to a pre-clinical study that explored how the structural analogues bisphenol-s (BPS) and bisphenol-f (BPF) interact with the chemical and electrical functions of heart cells.

The findings suggest that in terms of toxicity for heart function, these chemicals that are similar in structure to BPA may actually be safer for medically fragile heart cells, such as those in children with congenital heart disease. Previous research has found a high likelihood that BPA exposure may impact the heart’s electrical conductivity and disrupt heart rhythm, and patients are often exposed to the plastic via clinical equipment found in intensive care and in the operating room.

“There are still many questions that need to be answered about the safety and efficacy of using chemicals that look and act like BPA in medical settings, especially in terms of their potential contribution to endocrine disruption,” says Nikki Gillum Posnack, Ph.D., the poster’s senior author and a principal investigator in the Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Hospital. “What we can say is that, in this initial pre-clinical investigation, it appears that these structural analogues have less of an impact on the electrical activity within the heart and therefore, may be less likely to contribute to dysrhythmias.”

Future studies will seek to quantify the risk that these alternative chemicals pose in vulnerable populations, including pediatric cardiology and cardiac surgery patients. Since pediatric patients’ hearts are still growing and developing, the interactions may be different than what was seen in this pilot study.

Learn more the impacts of exposure to plastics such as bisphenol-A and plasticizers such as DEHP and MEHP that are commonly used in medical devices:

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Bisphenol-a Analogues May Be Safer Alternatives For Plastic Medical Products
Rafael Jaimes, Damon McCullough, Luther M Swift, Marissa Reilly, Morgan Burke, Jiansong Sheng, Javier Saiz, Nikki G Posnack
Poster Presentation by senior author Nikki G Posnack
CH.APS.01 – Translational Research in Congenital Heart Disease
AHA Scientific Sessions
November 16, 2019
1:30 p.m. – 2:00 p.m.

Newborn baby laying in crib

Can cells collected from bone marrow repair brain damage in babies with CHD?

Newborn baby laying in crib

The goal of the study will be to optimize brain development in babies with congenital heart disease (CHD) who sometimes demonstrate delay in the development of cognitive and motor skills.

Richard Jonas M.D., Children’s National chief of cardiac surgery, to highlight upcoming NIH-funded trial that will use cardiopulmonary bypass to deliver mesenchymal stromal cells for brain growth and regeneration

An upcoming clinical trial at Children’s National Hospital will harness cardiopulmonary bypass as a delivery mechanism for a novel intervention designed to stimulate brain growth and repair in children who undergo cardiac surgery for congenital heart disease (CHD).

The NIH has awarded Children’s National $2.5 million to test the hypothesis that mesenchymal stromal cells (MSCs), which have been shown to possess regenerative properties and the ability to modulate immune responses in a variety of diseases, collected from allogeneic bone marrow, may promote regeneration of damaged neuronal and glial cells in the early postnatal brain. If successful, the trial will determine the safety of the proposed treatment in humans and set the stage for a Phase 2 efficacy trial of what could potentially be the first treatment for brain damage in children with congenital heart disease. The study is a single-center collaboration between three Children’s National physician-researchers: Richard Jonas, M.D.Catherine Bollard, M.B.Ch.B., M.D. and Nobuyuki Ishibashi, M.D.

Dr. Jonas, chief of cardiac surgery at Children’s National, will outline the trial and its aims on Monday, November 18, 2019, at the American Heart Association’s Scientific Sessions 2019. Dr. Jonas was recently recognized by the Cardiac Neurodevelopmental Outcome Collaborative for his lifelong research of how cardiac surgery impacts brain growth and development in children with CHD.

Read more about the study: Researchers receive $2.5M grant to optimize brain development in babies with CHD.

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Regenerative Cell Therapy in Congenital Heart Disease – Protecting the Immature Brain
Presented by Richard Jonas, M.D.
AHA Scientific Sessions
Session CH.CVS.608 Congenital Heart Disease and Pediatric Cardiology Seminar: A Personalized Approach to Heart Disease in Children
9:50 a.m. to 10:05 a.m.
November 18, 2019

little girl reaching for gun

Empowering pediatricians to reduce preventable firearm injuries and deaths

little girl reaching for gun

Lenore Jarvis, M.D., MEd, FAAP, will participate in a symposium of surgeons, neurosurgeons and emergency medicine doctors during the American Academy of Pediatrics National Conference and Exhibition – the first time these groups have come together to help reduce the number of kids hurt or killed by firearms.

Lenore Jarvis, M.D., MEd, FAAP, remembers feeling fatigue and frustration when, despite her team’s herculean efforts, a 5-year-old died from accidental gunshot wounds. The preschooler had been feeling playful: He surprised a family member who mistook him for an intruder and fired, fatally wounding the child.

As an Emergency Medicine and Trauma Services specialist at Children’s National Hospital, Dr. Jarvis has cared for kids with a range of firearm-related injuries from accidental shootings, intentional acts of violence or suicide attempts. Even when children survive such traumatic injuries, their lives are indelibly altered.

“We’re trained to save lives, but we also want to prevent childhood injuries, if possible. As I considered this young child’s life ending so prematurely and so tragically, I thought I should do more. I could do more,” recalls Dr. Jarvis, the division’s director of advocacy and health policy.

To that end, in addition to advocacy at the regional and national level, on Oct. 26, 2019, Dr. Jarvis will participate in a four-hour symposium of surgeons, neurosurgeons and emergency medicine doctors during the American Academy of Pediatrics (AAP) National Conference and Exhibition – the first time these groups have come together to explore ways they can help to reduce the number of kids hurt or killed by firearms.

Dr. Jarvis will set the stage for the day’s collective call to action when she counsels pediatricians about how they can advocate within the clinic by simple actions such as:

  • Asking families if there are firearms in the home
  • Making time for such conversations during routine care, including well-child visits
  • Paying special attention to warning signs of suicide and depression
  • Having frank conversations with parents about curious toddlers

“The safest home is a home without a firearm. If that’s not possible, the firearm should be stored in a locked cabinet with the ammunition stored separately,” she says. “Toddlers are especially curious and they actively explore their environment. An unsecured firearm can be a tragic accident waiting to happen with curious young children in the home. And if teenagers happen upon the weapon, it could be used in a homicide or suicide.”

In addition to empowering clinicians to have these conversations routinely, symposium speakers will emphasize empowering parents to ask other families: “Is there an unlocked gun in your house?”

“It’s no different than a parent of a child with a life-threatening sensitivity to peanuts asking if there are peanuts in any home that child may visit,” she adds. “As one of the leading causes of death among children and youth, unsecured firearms are even more dangerous than peanuts. And families should feel comfortable making informed decisions about whether their children will be safe as they play and socialize with friends.”

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AAP National Conference and Exhibition presentation
Saturday, Oct. 26, 2:15 p.m. to 6:15 p.m. (ET)
“AAP NCE Section on Emergency Medicine/Section on Surgery/Section on Neurosurgery gun advocacy joint program”

doctor giving girl checkup

Decision support tool reduces unneeded referrals of low-risk patients with chest pain

doctor giving girl checkup

A simple evidence-based change to standard practice could avert needless referrals of low-risk patients to cardiac specialists, potentially saving nearly $4 million in annual health care spending while also easing worried parents’ minds.

Few events strike more fear in parents than hearing their child’s heart “hurts.”

When primary care pediatricians – who are on the frontline of triaging such distressing doctor visits – access a digital helping hand tucked into the patient’s electronic health record to help them make assessments, they are more likely to refer only the patients whose chest pain is rooted in a cardiac problem to a specialist.

That simple evidence-based change to standard practice could avert needless referrals of low-risk patients to cardiac specialists according to a quality-improvement project presented during the American Academy of Pediatrics (AAP) National Conference and Exhibition. This has the potential to save nearly $4 million in annual health care spending while also easing worried parents’ minds.

“Our decision support tool incorporates the know-how of providers and helps them to accurately capture the type of red flags that point to a cardiac origin for chest pain,” says Ashraf Harahsheh, M.D., FACC, FAAP, pediatric and preventive cardiologist and director of Resident Education in Cardiology at Children’s National Hospital. Those red flags include:

  • Abnormal personal medical history
    • Chest pain with exertion
    • Exertional syncope
    • Chest pain that radiates to the back, jaw, left arm or left shoulder
    • Chest pain that increases with supine position
    • Chest pain temporarily associated with a fever (>38.4°C)
  • A worrisome family history, including sudden unexplained death and cardiomyopathy.

“We know that evidence-based tools can be very effective in guiding physician behavior and reducing unnecessary testing and referrals which saves both the health care system in dollars and families in time and anxiety,” Dr. Harahsheh adds.

The abstract builds on a multi-institutional study published in Clinical Pediatrics in 2017 for which Dr. Harahsheh was lead author. More than 620,000 office-based visits (1.3%) to pediatricians in 2012 were for chest pain, he and co-authors wrote at the time. While children often complain of having chest pain, most of the time it is not due to an actual heart problem.

Over recent years, momentum has built for creating an evidence-based approach for determining which children with chest pain to refer to cardiac specialists. In response, the team’s quality-improvement tool, first introduced at two local primary pediatric offices, was expanded to the entire Children’s Pediatricians & Associates network of providers who offer pediatric primary care in Washington, D.C., and Maryland.

One daunting challenge: How to ensure that busy clinicians actually use the tool. To improve adoption, the project team embedded the decision support tool within the patient’s electronic medical record.  Now, they seek to make sure the tool gets used by more pediatricians around the country.

“If the chest pain decision support tool/medical red-flags criteria were adopted nationwide, we expect to save a minimum of $3.8 million in health care charges each year,” Dr. Harahsheh says. “That figure is very likely an underestimate of the true potential savings, because we did not calculate the value of lost productivity and other direct costs to families who shuttle from one appointment to the next.”

To ensure the changes stick, the team plans to train fledgling physicians poised to embrace the quality-improvement approach as they first launch their careers, and also look for evangelists within outpatient cardiology and pediatric clinics who can catalyze change.

“These types of quality-improvement projects require a change to the status quo. In order to be successful, we need members of the care team – including frontline clinicians and nurse practitioners – to champion change at the clinic level. With their help, we can continue to refine this tool and move toward nationwide implementation,” he explains.

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AAP National Conference and Exhibition presentation
Saturday, Oct. 26, 9 a.m. to 2 p.m. (ET)
H2086 Council on Quality Improvement and Patient Safety Program

Saturday, Oct. 26, noon to 1 p.m. (ET)
Poster viewing
“Reducing low-probability cardiology referrals for chest pain from primary care: a quality improvement initiative”
Ashraf Harahsheh, M.D., FACC, FAAP; Ellen Hamburger, M.D.; Lexi Crawford, M.D.; Christina Driskill, MPH, RN, CPN; Anusha Rao, MHSA; Deena Berkowitz, M.D., MPH

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Additional AAP 2019 activities featuring cardiology faculty at Children’s National Hospital include:

    • Rohan Kumthekar, M.D., recipient of the “Trainee Pediatric Cardiology Research Award” sponsored by the Children’s Heart Foundation
    • “Motion-corrected cardiac MRI limits anesthesia exposure and healthcare costs in children,” Adam B. Christopher, M.D.; Rachel Quinn, M.D.; Sara Zoulfagharian; Andrew Matisoff, M.D.; Russell Cross, M.D.; Adrienne Campbell-Washburn, Ph.D.; Laura Olivieri, M.D.
    • “Prevalence of abnormal echocardiograms in healthy, asymptomatic adolescents with Down syndrome,” Sarah B. Clauss, M.D.; Samuel S. Gidding M.D.; Claire I. Cochrane, BA; Rachel Walega, MS; Babette S. Zemel, Ph.D.; Mary E. Pipan, M.D.; Sheela N. Magge, M.D., MSCE;  Andrea Kelly, M.D., MSCE; Meryl S. Cohen, M.D.
    • “American College of Cardiology body mass index measurement and counseling quality improvement initiative,” Ashraf Harahsheh, M.D., FACC, FAAP; Arash Sabati, M.D., FACC; Jeffrey Anderson, M.D.; Clara Fitzgerald; Kathy Jenkins, M.D., MPH; Carolyn M. Wilhelm, M.D., MS, FACC, FAAP; Roy Jedeikin, M.D. FACC, MBA; Devyani Chowdhury, M.D.
Dr. Jonas and research collaborator Nobuyuki Ishibashi in the laboratory.

Cardiac surgery chief recognized for studies of surgery’s impacts on neurodevelopment

Dr. Jonas and research collaborator Nobuyuki Ishibashi in the laboratory.

Dr. Jonas and research collaborator Nobuyuki Ishibashi in the laboratory.

Richard Jonas, M.D., is this year’s recipient of the Newburger-Bellinger Cardiac Neurodevelopmental Award in recognition of his lifelong research into understanding the impact of cardiac surgery on the growth and development of the brain. The award was established in 2013 by the Cardiac Neurodevelopmental Outcome Collaborative (CNOC) to honor Jane Newburger and David Bellinger, pioneers in research designed to understand and improve neurodevelopmental outcomes for children with heart disease.

At Children’s National, Dr. Jonas’ laboratory studies of neuroprotection have been conducted in conjunction with Dr. Vittorio Gallo, director of neuroscience research at Children’s National, and Dr. Nobuyuki Ishibashi, director of the cardiac surgery research laboratory. Their NIH-supported studies have investigated the impact of congenital heart disease and cardiopulmonary bypass on the development of the brain, with particular focus on impacts to white matter, in people with congenital heart disease.

Dr. Jonas’s focus on neurodevelopment after cardiac surgery has spanned his entire career in medicine, starting with early studies in the Harvard psychology department where he developed models of ischemic brain injury. He subsequently undertook a series of highly productive pre-clinical cardiopulmonary bypass studies at the National Magnet Laboratory at MIT. These studies suggested that some of the bypass techniques used at the time were suboptimal. The findings helped spur a series of retrospective clinical studies and subsequently several prospective randomized clinical trials at Boston Children’s Hospital examining the neurodevelopmental consequences of various bypass techniques. These studies were conducted by Dr. Jonas and others, in collaboration with Dr. Jane Newburger and Dr. David Bellinger, for whom this award is named.

Dr. Jonas has been the chief of cardiac surgery and co-director of the Children’s National Heart Institute since 2004. He previously spent 20 years on staff at Children’s Hospital Boston including 10 years as department chief and as the William E. Ladd Chair of Surgery at Harvard Medical School.

As the recipient of the 2019 award, Dr. Jonas will deliver a keynote address at the 8th Annual Scientific Sessions of the Cardiac Neurodevelopmental Outcome Collaborative in Toronto, Ontario, October 11-13, 2019.

Mihailo Kaplarevic

Extracting actionable research data faster, with fewer hassles

Mihailo Kaplarevic

Mihailo Kaplarevic, Ph.D., the newly minted Chief Research Information Officer at Children’s National Hospital and Bioinformatics Division Chief at Children’s National Research Institute, will provide computational support, advice, informational guidance, expertise in big data and data analyses for researchers and clinicians.

Kaplarevic’s new job is much like the role he played most recently at the National Heart, Lung and Blood Institute (NHLBI), assembling a team of researchers and scientists skilled in computing and statistical analyses to assist as in-house experts for other researchers and scientists.

NHLBI was the first institute within the National Institutes of Health (NIH) family to set up a scientific information office. During his tenure, a half-dozen other NIH institutions followed, setting up the same entity to help bridge the enormous gap between basic and clinical science and everything related to IT.

“There is a difference compared with traditional IT support at Children’s National – which will remain in place and still do the same sort of things they have been doing so far,” he says of The Bear Institute for Health Innovation. “The difference is this office has experience in research because every single one of us was a researcher at a certain point in our career: We are published. We applied for grants. We lived the life of a typical scientist. On top of that, we’re coming from the computational world. That helps us bridge the gaps between research and clinical worlds and IT.”

Ultimately, he aims to foster groundbreaking science by recognizing the potential to enhance research projects by bringing expertise acquired over his career and powerful computing tools to help teams achieve their goals in a less expensive and more efficient way.

“I have lived the life of a typical scientist. I know exactly how painful and frustrating it can be to want to do something quickly and efficiently but be slowed by technological barriers,” he adds.

As just one example, his office will design the high-performance computing cluster for the hospital to help teams extract more useful clinical and research data with fewer headaches.

Right now, the hospital has three independent clinical systems storing patient data; all serve a different purpose. (And there are also a couple of research information systems, also used for different purposes.) Since databases are his expertise, he will be involved in consolidating data resources, finding the best way to infuse the project with the bigger-picture mission – especially for translational science – and creating meaningful, actionable reports.

“It’s not only about running fewer queries,” he explains. “One needs to know how to design the right question. One needs to know how to design that question in a way that the systems could understand. And, once you get the data back, it’s a big set of things that you need to further filter and carefully shape. Only then will you get the essence that has clinical or scientific value. It’s a long process.”

As he was introduced during a Children’s National Research Institute faculty meeting in late-September 2019, Kaplarevic joked that his move away from pure computer science into a health care and clinical research domain was triggered by his parents: “When my mom would introduce me, she would say ‘My son is a doctor, but not the kind of doctor who helps other people.’ ”

Some of that know-how will play out by applying tools and methodology to analyze big data to pluck out the wheat (useful data) from the chaff in an efficient and useful way. On projects that involve leveraging cloud computing for storing massive amounts of data, it could entail analyzing the data wisely to reduce its size when it comes back from the cloud – when the real storage costs come in. “You can save a lot of money by being smart about how you analyze data,” he says.

While he expects his first few months will be spent getting the lay of the land, understanding research project portfolios, key principal investigators and the pediatric hospital’s biggest users in the computational domain, he has ambitious longer-term goals.

“Three years from now, I would like this institution to say that the researchers are feeling confident that their research is not affected by limitations related to computer science in general. I would like this place to become a very attractive environment for up-and-coming researchers as well as for established researchers because we are offering cutting-edge technological efficiencies; we are following the trends; we are a secure place; and we foster science in the best possible way by making computational services accessible, affordable and reliable.”

Rohan Kumthekar and Charles Berul

Rohan Kumthekar wins AAP’s Cardiology Research Fellowship Award

Rohan Kumthekar and Charles Berul

Dr. Kumthekar and Charles Berul, M.D., chief of Cardiology, discuss less invasive approaches for infants who require pacemaker and defibrillator placements.

Efforts to develop surgical approaches that would eliminate the need for complex, open surgery when placing pacemakers in tiny infants and young children has earned cardiology fellow Rohan Kumthekar, M.D., the American Academy of Pediatrics Cardiology Research Fellowship Award.

“Placing a pacemaker in a small child is different than operating on an adult, due to their small chest cavity and narrow blood vessels,” said Dr. Kumthekar in a 2018 interview about the proof of concept study for this work. “By eliminating the need to cut through the sternum or the ribs and fully open the chest to implant a pacemaker, the current model, we can cut down on surgical time and help alleviate pain.”

“We hope that this approach to lead placement eliminates the need for surgery in this group of pediatric patients,” he further explains in the 2019 award announcement. “This research could have a transformative impact in changing the current clinical standard for pacemaker and ICD implantation in pediatric patients by converting an open surgical approach to a minimally invasive procedure.”

The award, which is supported by the Children’s Heart Foundation, provides research support for an individual who has demonstrated aptitude for basic science or clinical science research during their pediatric cardiology fellowship.

Lee Beers

Getting to know Lee Beers, M.D., FAAP, future president-elect of AAP

Lee Beers

Lee Savio Beers, M.D., FAAP, Medical Director of Community Health and Advocacy at the Child Health Advocacy Institute (CHAI) at Children’s National Hospital carved out a Monday morning in late-September 2019, as she knew the American Academy of Pediatrics (AAP) would announce the results of its presidential election, first by telephone call, then by an email to all of its members.  Her husband blocked off the morning as well to wait with her for the results.  She soon got the call that she was elected by her peers to become AAP president-elect, beginning Jan. 1, 2020. Dr. Beers will then serve as AAP president in 2021 for a one-year term.

That day swept by in a rush, and then the next day she was back in clinic, caring for her patients, some of them teenagers whom she had taken care of since birth. Seeing children and families she had known for such a long time, some of whom had complex medical needs, was a perfect reminder of what originally motivated Dr. Beers to be considered as a candidate in the election.

“When we all work together – with our colleagues, other professionals, communities and families – we can make a real difference in the lives of children.  So many people have reached out to share their congratulations, and offer their support or help. There is a real sense of collaboration and commitment to child health,” Dr. Beers says.

That sense of excitement ripples through Children’s National.

“Dr. Beers has devoted her career to helping children. She has developed a national advocacy platform for children. I can think of no better selection for the president-elect role of the AAP. She will be of tremendous service to children within AAP national leadership,” says Kurt Newman, M.D., Children’s National Hospital President and CEO.

AAP comprises 67​,000 pediatricians, and its mission is to promote and safeguard the health and well-being of all children – from infancy to adulthood.

The daughter of a nuclear engineer and a schoolteacher, Dr. Beers knew by age 5 that she would become a doctor. Trained as a chemist, she entered the Emory University School of Medicine after graduation. After completing residency at the Naval Medical Center, she became the only pediatrician assigned to the Guantanamo Bay Naval Station.

That assignment to Cuba, occurring so early in her career, turned out to be a defining moment that shapes how she partners with families and other members of the team to provide comprehensive care.

“I was a brand-new physician, straight out of residency, and was the only pediatrician there so I was responsible for the health of all of the kids on the base. I didn’t know it would be this way at the time, but it was formative. It taught me to take a comprehensive public health approach to taking care of kids and their families,” she recalls.

On the isolated base, where she also ran the immunization clinic and the nursery, she quickly learned she had to judiciously use resources and work together as a team.

“It meant that I had to learn how to lead a multi-disciplinary team and think about how our health care systems support or get in the way of good care,” she says.

One common thread that unites her past and present is helping families build resiliency to shrug off adversity and stress.

“The base was a difficult and isolated place for some families and individuals, so I thought a lot about how to support them. One way is finding strong relationships where you are, which was important for patients and families miles away from their support systems. Another way is to find things you could do that were meaningful to you.”

Cuba sits where the Atlantic Ocean, Caribbean Sea and Gulf of Mexico meet. Dr. Beers learned how to scuba dive there – something she never would have done otherwise – finding it restful and restorative to appreciate the underwater beauty.

“I do think these lessons about resilience are universal. There are actually a lot of similarities between the families I take care of now, many of whom are in socioeconomically vulnerable situations, and military families when you think about the level of stress they are exposed to,” she adds.

Back stateside in 2001, Dr. Beers worked as a staff pediatrician at the National Naval Medical Center in Bethesda, Maryland, and Walter Reed Army Medical Center in Washington, D.C. In 2003, Dr. Beers joined Children’s National Hospital as a general pediatrician in the Goldberg Center for Community Pediatric Health. Currently, she oversees the DC Collaborative for Mental Health in Pediatric Primary Care, a public-private coalition that elevates the standards of mental health care for all children, and is Co-Director of the Early Childhood Innovation Network. She received the Academic Pediatric Association’s 2019 Public Policy and Advocacy Award.

As a candidate, Dr. Beers pledged to continue AAP’s advocacy and public policy efforts and to further enhance membership diversity and inclusion. Among her signature issues:

  • Partnering with patients, families, communities, mental health providers and pediatricians to co-design systems to bolster children’s resiliency and to alleviate growing pediatric mental health concerns
  • Tackling physician burnout by supporting pediatricians through office-based education and systems reforms
  • Expanding community-based prevention and treatment

“I am humbled and honored to have the support of my peers in taking on this newest leadership role,” says Dr. Beers. “AAP has been a part of my life since I first became a pediatrician, and my many leadership roles in the DC chapter and national AAP have given me a glimpse of the collective good that pediatricians can accomplish by working together toward common strategic goals.”

AAP isn’t just an integral part of her life, it’s where she met her future husband, Nathaniel Beers, M.D., MPA, FAAP, President of The HSC Health Care System. The couple’s children regularly attended AAP meetings with them when they were young.

Just take a glimpse at Lee Beers’ Twitter news feed. There’s a steady stream of images of her jogging before AAP meetings to amazing sunrises, jogging after AAP meetings to stellar sunsets and always, always, images of the entire family, once collectively costumed as The Incredibles.

“I really do believe that we have to set an example: If we are talking about supporting children and families in our work, we have to set that example in our own lives. That looks different for everyone, but as pediatricians and health professionals, we can model prioritizing our families while still being committed to our work,” she explains.

“Being together in the midst of the craziness is just part of what we do as a family. We travel a lot, and our kids have gone with us to AAP meetings since they were infants. My husband even brought our infant son to a meeting at the mayor’s office when he was on paternity leave. Recognizing that not everyone is in a position to be able to do things like that, it’s important for us to do it – to continue to change the conversation and make it normal to have your family to be part of your whole life, not have a separate work life and a separate family life.”

Dr. DeBiasi

Staying one step ahead of deadly Ebola

Dr. DeBiasi

An ongoing outbreak of Ebola virus since 2018 in the Democratic Republic of the Congo that has resulted in millions of travelers being screened at checkpoints, hundreds of thousands of vaccinations and thousands of deaths is a stark reminder of the need to remain one step ahead of the deadly disease.

To that end, one-half dozen personnel from Children’s National in Washington, D.C., including infectious diseases experts, critical care nurses and laboratory personnel traveled to New York in mid-August for an interactive workshop sponsored by the National Ebola Training and Education Center. They covered how to correctly don and doff protective gear, safely collect, handle and process specimens and discuss the special circumstances that arise when caring for pediatric patients, among other topics.

“Since 2014, Children’s National has evaluated 6 children with exposure as Persons Under Investigation of  Ebola virus disease, 4 of  whom required extended inpatient hospitalization under full isolation precautions,” says Roberta L. DeBiasi, M.D., MS, chief of the Division of Pediatric Infectious Diseases. “As a designated Ebola Treatment Center, we must continue our preparedness to care for additional patients with suspected and proven Ebola infection.

“Hands-on training and  drilling offer Children’s National personnel an opportunity to continue to test, evaluate and optimize our institutional Ebola response plan and procedures to maintain our preparedness for the needs of future patients,” adds Dr. DeBiasi.

In addition to Dr. DeBiasi, members of the Children’s National Special Pathogens Isolation Unit team who attended the Emerging Infectious Disease Workshop included:

  • Zohreh Hojjati, Laboratory Medicine.
  • Kristin Elizabeth Mullins, Clinical Lab Director, Laboratory Medicine.
  • Daniel Schroeder, Registered Nurse II, Pediatric Intensive Care Unit (PICU).
  • Melissa Taylor, Registered Nurse II, PICU.
  • Heather Wellman, Registered Nurse II, PICU.

“Among the keys to Children’s National serving as a national exemplar for pediatric Ebola care, is the stability of our multidisiciplinary care team and our institutional commitment to ongoing training,” Dr. DeBiasi adds.

During a Grand Rounds presentation at Children’s National in mid-August, Dr. DeBiasi provided updates about recent global infectious disease outbreaks affecting pediatric patients including Ebola, measles, acute flaccid myelitis and Zika Virus. An interdisciplinary panel of Children’s National experts, including nurses, transport specialists, infectious disease and intensive care experts directly involved in caring for Ebola Persons Under Investigation, demonstrated personal protective equipment and fielded questions from staff. The overview also outlined Children’s National institutional expertise and response, including the Congenital Zika Virus Program, the Acute Flaccid Myelitis Task Force, the Special Isolation Unit for Ebola and other highly contagious infectious diseases.

View Ebola preparedness photo gallery.

Dr. Eurgenie Heitmiller

The origins of a go-to perioperative crisis app

Dr. Eurgenie Heitmiller

Children’s Chief of Anesthesiology and Pain Medicine, Dr. Heitmiller, was part of the team that originally launched the peer-reviewed perioperative crisis app, Pedi Crisis.

Around the same time that Atul Gawande and colleagues were developing adult operating room crisis checklists, a dedicated group of expert pediatric anesthesiologists were working on a set of checklists for pediatric specific, peer-reviewed algorithms to treat critical events in the perioperative setting.

Eugenie Heitmiller, M.D., chief of Anesthesiology, Pain and Perioperative Medicine at Children’s National Health System, was one of the initiators of what is known today as the Pedi Crisis App—a widely used reference tool designed to support clinician responses to life-threatening critical events.

Dr. Heitmiller and her colleagues on the Quality and Safety Committee of the Society for Pediatric Anesthesia (SPA) sought to create this series of standard algorithms that could be referenced both as teaching tools and as cognitive aids to be used in real time during rare critical occurrences in the perioperative setting.

“Most kids do well under anesthesia, but every once in a while, you have a child who has an event you don’t see that often, no matter how experienced you are,” she says. Having these checklists means we have a peer-reviewed, expert checklist at our fingertips.”

The original version of the checklists launched in 2010 as “Pediatric Critical Event Checklists”,  a Microsoft PowerPoint file that could be downloaded from the SPA website. Eventually, the checklists were adapted into an iPhone application as well as being translated into several languages.

Years after launch, these tools continue to be a mainstay for education, training, and critical event preparations for pediatric anesthesiologists and perioperative staff. A 2017 study found that in a three-month period of 2014, the app was accessed more than 4,000 times in 108 countries.

This year, the organizers of the joint SPA and American Academy of Pediatrics (AAP) meeting invited Dr. Heitmiller to moderate a panel that included talks on the launch of Pedi Crisis App 2.0 and its subsequent revisions. The newest edition of the Critical Events Checklists adds critical components including an updated smartphone app available for both the iPhone and Android, and the latest peer-reviewed content.

Pedi Crisis 2.0 also takes into account how people access and use the tool by incorporating elements that address human factors. The development team brought in  NASA senior research psychologist, Barbara Burian, Ph.D., to help make the content as intuitive as possible for quick access, accurate presentation, and recollection, even in a crisis. And, as Dr. Heitmiller points out, because pulling out a cell phone isn’t always the most realistic option in a sterile operating room environment, the content is always available for free outside of the mobile platform in a downloadable format on the SPA website so it can be accessed on any computer screen in any location.

Paradoxical outcomes for Zika-exposed tots

In the midst of an unprecedented Zika crisis in Brazil, there were a few flickers of hope: Some babies appeared to be normal at birth, free of devastating birth defects that affected other Brazilian children exposed to the virus in utero.

In the midst of an unprecedented Zika crisis in Brazil, there were a few flickers of hope: Some babies appeared to be normal at birth, free of devastating birth defects that affected other Brazilian children exposed to the virus in utero. But according to a study published online July 8, 2019, in Nature Medicine and an accompanying commentary co-written by a Children’s National clinician-researcher, the reality for Zika-exposed infants is much more complicated.

Study authors led by Karin Nielsen-Saines at David Geffen UCLA School of Medicine followed 216 infants in Rio de Janeiro who had been exposed to the Zika virus during pregnancy, performing neurodevelopmental testing when the babies ranged in age from 7 to 32 months. These infants’ mothers had had Zika-related symptoms themselves, including rash.

Although many children had normal assessments, 29% scored below average in at least one domain of neurological development, including cognitive performance, fine and gross motor skills and expressive language, Sarah B. Mulkey, M.D., Ph.D., and a colleague write in a companion commentary published online by Nature Medicine July 29, 2019.

The study authors found progressively higher risks for developmental, hearing and eye abnormality depending on how early the pregnancy was at the time the infants were exposed. Because Zika virus has an affinity for immature neurons, even babies who were not born with microcephaly remained at continued risk for suffering abnormalities.

Of note, 24 of 49 (49%) infants who had abnormalities at birth went on to have normal test results in the second or third year of life. By contrast, 17 of 68 infants (25%) who had normal assessments at birth had below-average developmental testing or had abnormalities in hearing or vision by age 32 months.

“This work follows babies who were born in 2015 and 2016. It’s heartening that some babies born with abnormalities tested in the normal range later in life, though it’s unclear whether any specific interventions help to deliver these positive findings,” says Dr. Mulkey, a fetalneonatal neurologist in the Division of Fetal and Transitional Medicine at Children’s National in Washington, D.C. “And it’s quite sobering that babies who appeared normal at birth went on to develop abnormalities due to that early Zika exposure.”

It’s unclear how closely the findings apply to the vast majority of U.S. women whose Zika infections were asymptomatic.

“This study adds to the growing body of research that argues in favor of ongoing follow-up for Zika-exposed children, even if their neurologic exams were reassuring at birth,” Dr. Mulkey adds. “As Zika-exposed children approach school age, it’s critical to better characterize the potential implications for the education system and public health.”

In addition to Dr. Mulkey, the perspective’s senior author, William J. Muller, Northwestern University, was the commentary’s lead author.

zika virus

Neuroimaging essential for Zika cases

zika virus

About three years ago, Zika virus emerged as a newly recognized congenital infection, and a growing body of research indicates the damage it causes differs from other infections that occur in utero.

Seventy-one of 110 Brazilian infants at the highest risk for experiencing problems due to exposure to the Zika virus in the womb experienced a wide spectrum of brain abnormalities, including calcifications and malformations in cortical development, according to a study published July 31, 2019 in JAMA Network Open.

The infants were born at the height of Brazil’s Zika epidemic, a few months after the nation declared a national public health emergency. Already, many of the infants had been classified as having the severe form of congenital Zika syndrome, and many had microcephaly, fetal brain disruption sequence, arthrogryposis and abnormal neurologic exams at birth.

These 110 infants “represented a group of ZIKV-exposed infants who would be expected to have a high burden of neuroimaging abnormalities, which is a difference from other reported cohorts,” Sarah B. Mulkey, M.D., Ph.D., writes in an invited commentary published in JAMA Network Open that accompanies the Rio de Janeiro study. “Fortunately, many ZIKV-exposed infants do not have abnormal brain findings or a clinical phenotype associated with congenital Zika syndrome,” adds Dr. Mulkey, a fetalneonatal neurologist in the Division of Fetal and Transitional Medicine at Children’s National in Washington, D.C.

Indeed, a retrospective cohort of 82 women exposed to Zika during their pregnancies led by a research team at Children’s National found only three pregnancies were complicated by severe fetal brain abnormalities. Compared with the 65% abnormal computed tomography (CT) or magnetic resonance imaging (MRI) findings in the new Brazilian study, about 1 in 10 (10%) of babies born to women living in the continental U.S. with confirmed Zika infections during pregnancy had Zika-associated birth defects, according to the Centers for Disease Control and Prevention.

“There appears to be a spectrum of brain imaging abnormalities in ZIKV-exposed infants, including mild, nonspecific changes seen at cranial US [ultrasound], such as lenticulostriate vasculopathy and germinolytic cysts, to more significant brain abnormalities, such as subcortical calcifications, ventriculomegaly and, in its most severe form, thin cortical mantle and fetal brain disruption sequence,” Dr. Mulkey writes.

About three years ago, Zika virus emerged as a newly recognized congenital infection, and a growing body of research indicates the damage it causes differs from other infections that occur in utero. Unlike congenital cytomegalovirus infection, cerebral calcifications associated with Zika are typically subcortical, Dr. Mulkey indicates. What’s more, fetal brain disruption sequence seen in Zika-exposed infants is unusual for other infections that can cause microcephaly.

“Centered on the findings of Pool, et al, and others, early neuroimaging remains one of the most valuable investigations of the Zika-exposed infant,” Dr. Mulkey writes, including infants who are not diagnosed with congenital Zika syndrome.  She recommends:

  • Cranial ultrasound as the first-line imaging option for infants, if available, combined with neurologic and ophthalmologic exams, and brainstem auditory evoked potentials
  • Zika-exposed infants with normal cranial ultrasounds do not need additional imaging unless they experience a developmental disturbance
  • Zika-exposed infants with abnormal cranial ultrasounds should undergo further neuroimaging with low-dose cranial CT or brain MRI.

Autonomic nervous system appears to function well regardless of mode of childbirth

Late in pregnancy, the human body carefully prepares fetuses for the rigors of life outside the protection of the womb. Levels of cortisol, a stress hormone, ramp up and spike during labor. Catecholamines, another stress hormone, also rise at birth, helping to kick start the necessary functions that the baby will need to regulate breathing, heartbeat, blood pressure and energy metabolism levels at delivery. Oxytocin surges, promoting contractions for the mother during labor and stimulating milk production after the infant is born.

These processes also can play a role in preparing the fetal brain during the transition to life outside the womb by readying the autonomic nervous system and adapting its cerebral connections. The autonomic nervous system acts like the body’s autopilot, taking in information it needs to ensure that internal organs run steadily without willful action, such as ensuring the heart beats and eyelids blink at steady intervals. Its yin, the sympathetic division, stimulates body processes while its yang, the parasympathetic division, inhibits them.

Infants born preterm have reduced autonomic function compared with their full-term peers and also face possible serious neurodevelopmental impairment later in life. But is there a difference in autonomic nervous system function for full-term babies after undergoing labor compared with infants delivered via cesarean section (C-section)?

A team from the Children’s National Inova Collaborative Research Program (CNICA) – a research collaboration between Children’s National in Washington, D.C., and Inova Women’s and Children’s Hospital in Virginia – set out to answer that question in a paper published online July 30, 2019, in Scientific Reports.

They enrolled newborns who had experienced normal, full-term pregnancies and recorded their brain function and heart performance when they were about 2 days old. Infants whose conditions were fragile enough to require observation in the neonatal intensive care unit were excluded from the study. Of 167 infants recruited for the prospective cohort study, 118 newborns had sufficiently robust data to include them in the research.  Of these newborns:

  • 62 (52.5%) were born by vaginal delivery
  • 22 (18.6%) started out with vaginal delivery but ultimately switched to C-section based on failure to progress, failed labor induction or fetal intolerance to labor
  • And 34 (28.8%) were born by elective C-section.

The CNICA research team swaddled infants for comfort and slipped electrode nets over their tiny heads to simultaneously measure heart rate variability and electrocortical function through non-invasive techniques. The team hypothesized that infants who had been exposed to labor would have enhanced autonomic tone and higher cortical electroencephalogram (EEG) power than babies born via C-section.

“In a low-risk group of babies born full-term, the autonomic nervous system and cortical systems appear to function well regardless of whether infants were exposed to labor prior to birth,” says Sarah B. Mulkey, M.D., Ph.D., a fetalneonatal neurologist in the Division of Fetal and Transitional Medicine at Children’s National and the study’s lead author.

However, infants born by C-section following a period of labor had significantly increased accelerations in their heart rates. And the infants born by C-section during labor had significantly lower relative gamma frequency EEG at 25.2 hours old compared with the other two groups studied.

“Together these findings point to a possible increased stress response and arousal difference in infants who started with vaginal delivery and finished delivery with C-section,” Dr. Mulkey says. “There is so little published research about the neurologic impacts of the mode of delivery, so our work helps to provide a normal reference point for future studies looking at high-risk infants, including babies born preterm.”

Because the research team saw little differences in autonomic tone or other EEG frequencies when the infants were 1 day old, future research will explore these measures at different points in the newborns’ early life as well as the role of the sleep-wake cycle on heart rate variability.

In addition to Dr. Mulkey, study co-authors include Srinivas Kota, Ph.D., Rathinaswamy B. Govindan, Ph.D., Tareq Al-Shargabi, MSc, Christopher B. Swisher, BS, Laura Hitchings, BScM, Stephanie Russo, BS, Nicole Herrera, MPH, Robert McCarter, ScD, and Senior Author Adré  J. du Plessis, M.B.Ch.B., MPH, all of Children’s National; and Augustine Eze Jr., MS, G. Larry Maxwell, M.D., and Robin Baker, M.D., all of Inova Women’s and Children’s Hospital.

Financial support for research described in this post was provided by the National Institutes of Health National Center for Advancing Translational Sciences under award numbers UL1TR001876 and KL2TR001877.

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.

Denice Cora-Bramble with the Mayor’s Commission on Healthcare Systems Transformation

Denice Cora-Bramble, M.D., MBA, selected for Mayor’s Commission on Healthcare Systems Transformation

Denice Cora-Bramble with the Mayor’s Commission on Healthcare Systems Transformation

Photo credit: Executive Office of the Mayor

Denice Cora-Bramble, M.D., MBA, chief medical officer and executive vice president of Ambulatory and Community Health Services at Children’s National, has been selected to serve as a member of the Mayor’s Commission on Healthcare Systems Transformation. Established by Mayor Muriel Bowser, the commission will make recommendations on strategies and investments necessary to transform health care delivery in the District of Columbia.

Dr. Cora-Bramble is one of three representatives appointed to the commission from specialty hospitals in the District. “I am honored to have been invited to participate in the commission’s important discussions,” she says.

While D.C. has many resources related to health care and is home to several acute care hospitals, residents still need help accessing services. The 27-member commission will work to alleviate these challenges and over the next six months they will develop recommendations for improving access to primary, acute and specialty care services, addressing health system capacity issues for inpatient, outpatient, pre-hospital and emergency room services and maternal health.

The commission will also work to promote equitable acute care and specialty services in communities east of the Anacostia River.

“I’m looking forward to serving as a resource to citizens living within the District,” says Dr. Cora-Bramble.  “I am hopeful that the group’s recommendations will improve the delivery of health services, particularly for vulnerable and underserved populations.”

Dr. Cora-Bramble joined Children’s National in 2002. In her role as chief medical officer, she leads the tri-state clinical operations of Children’s National primary and specialty sites, including regional outpatient centers, emergency departments, community health centers, pediatric practices, school-based health centers, mobile medical units and nursing services in D.C. Public Schools and Public Charter Schools. She also oversees the telemedicine program and the Children’s National Health Network.

Children’s National ranked No. 6 overall and No. 1 for newborn care by U.S. News

Children’s National in Washington, D.C., is the nation’s No. 6 children’s hospital and, for the third year in a row, its neonatology program is No.1 among all children’s hospitals providing newborn intensive care, according to the U.S. News Best Children’s Hospitals annual rankings for 2019-20.

This is also the third year in a row that Children’s National has been in the top 10 of these national rankings. It is the ninth straight year it has ranked in all 10 specialty services, with five specialty service areas ranked among the top 10.

“I’m proud that our rankings continue to cement our standing as among the best children’s hospitals in the nation,” says Kurt Newman, M.D., President and CEO for Children’s National. “In addition to these service lines, today’s recognition honors countless specialists and support staff who provide unparalleled, multidisciplinary patient care. Quality care is a function of every team member performing their role well, so I credit every member of the Children’s National team for this continued high performance.”

The annual rankings recognize the nation’s top 50 pediatric facilities based on a scoring system developed by U.S. News. The top 10 scorers are awarded a distinction called the Honor Roll.

“The top 10 pediatric centers on this year’s Best Children’s Hospitals Honor Roll deliver outstanding care across a range of specialties and deserve to be nationally recognized,” says Ben Harder, chief of health analysis at U.S. News. “According to our analysis, these Honor Roll hospitals provide state-of-the-art medical expertise to children with rare or complex conditions. Their rankings reflect U.S. News’ assessment of their commitment to providing high-quality, compassionate care to young patients and their families day in and day out.”

The bulk of the score for each specialty is based on quality and outcomes data. The process also includes a survey of relevant specialists across the country, who are asked to list hospitals they believe provide the best care for patients with challenging conditions.

Below are links to the five specialty services that U.S. News ranked in the top 10 nationally:

The other five specialties ranked among the top 50 were cardiology and heart surgery, diabetes and endocrinology, gastroenterology and gastro-intestinal surgery, orthopedics, and urology.

Vittorio Gallo Alpha Omega Alpha Award

Vittorio Gallo, Ph.D., inducted into Alpha Omega Alpha

Vittorio Gallo Alpha Omega Alpha Award

Vittorio Gallo, Ph.D., Chief Research Officer at Children’s National, was inducted into Alpha Omega Alpha (AΩA), a national medical honor society that since 1902 has recognized excellence, leadership and research in the medical profession.

“I think it’s great to receive this recognition. I was very excited and surprised,” Gallo says of being nominated to join the honor society.

“Traditionally AΩA membership is based on professionalism, academic and clinical excellence, research, and community service – all in the name of ‘being worthy to serve the suffering,’ which is what the Greek letters AΩA stand for,” says Panagiotis Kratimenos, M.D., Ph.D., an ΑΩΑ member and attending neonatologist at Children’s National who conducts neuroscience research under Gallo’s mentorship. Dr. Kratimenos nominated his mentor for induction.

“Being his mentee, I thought Gallo was an excellent choice for AΩΑ faculty member,” Dr. Kratimenos says. “He is an outstanding scientist, an excellent mentor and his research is focused on improving the quality of life of children with brain injury and developmental disabilities – so he serves the suffering. He also has mentored numerous physicians over the course of his career.”

Gallo’s formal induction occurred in late May 2019, just prior to the medical school graduation at the George Washington University School of Medicine & Health Sciences (GWSMHS) and was strongly supported by Jeffrey S. Akman, Vice President for Health Affairs and Dean of the university’s medical school.

“I’ve been part of Children’s National and in the medical field for almost 18 years. That’s what I’m passionate about: being able to enhance translational research in a clinical environment,” Gallo says. “In a way, this recognition from the medical field is a perfect match for what I do. As Chief Research Officer at Children’s National, I am charged with continuing to expand our research program in one of the top U.S. children’s hospitals. And, as Associate Dean for Child Health Research at GWSMHS, I enhance research collaboration between the two institutions.”

Sadiqa Kendi

Sadiqa Kendi, M.D., FAAP, CPST, is 2019 Bloomberg Fellow

Sadiqa Kendi

Sadiqa Kendi, M.D., FAAP, CPST, a pediatric emergency physician at Children’s National and medical director of Safe Kids DC, is among the 2019 cohort of Bloomberg Fellows, an initiative that provides world-class training to public health professionals tackling some of the most intractable challenges facing the U.S.

The Bloomberg American Health Initiative at the Johns Hopkins Bloomberg School of Public Health on June 6, 2019, announced fellows who will receive full scholarships to earn an MPH or DrPH as they tackle five U.S. health challenges: addiction and overdose, environmental challenges, obesity and the food system, risks to adolescent health and violence. Now in its third year, the largest group of fellows to date includes representatives from organizations headquartered in 24 states and the District of Columbia.

As part of her environmental challenges fellowship, Dr. Kendi will attempt to lessen the significant morbidity and mortality suffered by children, especially children of color, due to unintentional injuries. Children’s emergency department handles more than 100,000 pediatric visits per year, 1,200 of which result in hospital admission.

“The numbers are staggering: 25% of emergency department visits by kids and more than $28 billion in health care spending are associated with injuries. These preventable injuries claim the highest number of pediatric lives, and children of color and lower income families often disproportionately bear this burden,” Dr. Kendi says.

Bloomberg Fellows Graphic

“Regrettably, I have seen the personal toll close up, and it has been sobering to hug a sobbing parent whose child clings to life after being struck by a car; to clasp the hand of a frightened child who has fallen from playground equipment and suffered a severe fracture; to see the angst written on a caregiver’s face as I lead our team in trying to save a life that easily could have been safeguarded by installing a window guard,” she adds.

Under the auspices of Safe Kids District of Columbia, Dr. Kendi is developing a one-stop Safety Center at Children’s National to provide injury prevention equipment and education to families in five focus areas: child passenger safety, home, pedestrian, sleep and sports.

Safe Kids Worldwide, the umbrella non-profit organization for Safe Kids DC, started at Children’s National and has grown to more than 400 coalitions around the world. Safe Kids DC is the local coalition that is working to address the burden of injury in local District of Columbia communities.

“I’m grateful to be named a Bloomberg Fellow because this opportunity will enable me to better understand the theories, methods of evaluation and tools for addressing the burden of injury in the District of Columbia, including how to assess and address the built environment. This training will help me to better lead my Safe Kids DC team in developing projects, outreach programs and legislative advocacy that have the potential to directly impact the communities we serve,” she adds.

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.