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.

Schistosoma haematobium egg

For hemorrhagic cystitis, harnessing the power of a parasite

Schistosoma haematobium egg

“Urogenital Schistosoma infestation, which is caused by S. haematobium, also causes hemorrhagic cystitis, likely by triggering inflammation when the parasite’s eggs are deposited in the bladder wall or as eggs pass from the bladder into the urinary stream. S. haematobium eggs secrete proteins, including IPSE, that ensure human hosts are not so sickened that they succumb to hemorrhagic cystitis,” says Michael H. Hsieh, M.D., Ph.D.

Every year, hundreds of thousands of U.S. patients – and even more throughout the world – are prescribed cyclophosphamide or ifosfamide. These two chemotherapy drugs can be life-saving for a wide range of pediatric cancers, including leukemias and cancers of the eyes and nerves. However, these therapies come with a serious side effect: Both cause hemorrhagic cystitis in up to 40 percent of patients. This debilitating condition is characterized by severe inflammation in the bladder that can cause tremendous pain, life-threatening bleeding, and frequent and urgent urination.

Infection with a parasitic worm called Schistosoma haematobium also causes hemorrhagic cystitis, but this organism has a fail-safe: To keep its host alive, the parasite secretes a protein that suppresses inflammation and the associated pain and bleeding.

In a new study, a Children’s-led research team harnessed this protein to serve as a new therapy for chemotherapy-induced hemorrhagic cystitis.

“Urogenital Schistosoma infestation, which is caused by S. haematobium, also causes hemorrhagic cystitis, likely by triggering inflammation when the parasite’s eggs are deposited in the bladder wall or as eggs pass from the bladder into the urinary stream. S. haematobium eggs secrete proteins, including IPSE, that ensure human hosts are not so sickened that they succumb to hemorrhagic cystitis,” says Michael H. Hsieh, M.D., Ph.D., senior author of the study published April 3, 2018, by The FASEB Journal. “This work in an experimental model is the first published report of exploiting an uropathogen-derived host modulatory molecule in a clinically relevant model of bladder disease, and it points to the potential utility of this as an alternate treatment approach.”

S. mansoni IPSE binds to Immunoglobulin E (IgE), an antibody produced by the immune system that is expressed on the surface of basophils, a type of immune cell; and mast cells, another immune cell that mediates inflammation; and sequesters chemokines, signaling proteins that alert white cells to infection sites. The team produced an ortholog of the uropathogen-derived protein. A single IV dose proved superior to multiple doses of 2-Mercaptoethane sulfonate sodium (MESNA), the current standard of care, in suppressing chemotherapy-induced bladder hemorrhaging in an experimental model. It was equally potent as MESNA in dampening chemotherapy-induced pain, the research team finds.

“The current array of medicines we use to treat hemorrhagic cystitis all have shortcomings, so there is a definite need for novel therapeutic options,” says Dr. Hsieh, a Children’s National Health System urologist. “And other ongoing research projects have the potential to further expand patients’ treatment options by leveraging other urogenital parasite-derived, immune-modulating molecules to treat inflammatory bowel diseases and autoimmune disorders.”

Future research will aim to describe the precise molecular mechanisms of action, as well as to generate other orthologs that boost efficacy while reducing side effects.

In addition to Dr. Hsieh, Children’s study co-authors include Lead Author, Evaristus C. Mbanefo; Loc Le and Luke F. Pennington; Justin I. Odegaard and Theodore S. Jardetzky, Stanford University; Abdulaziz Alouffi, King Abdulaziz City for Science and Technology; and Franco H. Falcone, University of Nottingham.

Financial support for this research was provided by National Institutes of Health under award number RO1-DK113504.

Eric Vilain

Exploring differences of sex development

Eric Vilain, M.D., Ph.D.

Eric Vilain, M.D., Ph.D., analyzes the genetic mechanisms of sex development to give families more answers that will help them make better treatment (or non treatment) decisions for a child diagnosed with DSD.

Eric Vilain, M.D., Ph.D., is well versed in the “world of uncertainty” that surrounds differences of sex development. Since joining Children’s National as the director of the Center for Genetic Medicine Research in 2017, he’s shared with our research and clinical faculty and staff his expertise about the ways that genetic analysis might help address some of the complex social, cultural and medical implications of these differences.

Over the summer, he gave a keynote address entitled “Disorders/Differences of Sex Development: A World of Uncertainty” during Children’s National’s Research and Education Week, an annual celebration of research, education, innovation and scholarship at Children’s National and around the world. In January 2018, he shared a more clinically oriented version of the talk at a special Children’s National Grand Rounds session.

The educational objective of these talks is to inform researchers and providers about the mechanisms of differences of sex development (DSD), which are defined as congenital conditions in which the development of chromosomal, gonadal or anatomical sex is atypical.

The primary goal, though, is to really shine light on the complexity of this hot topic, and share how powerful genetic tools can be used to provide vital, concrete information for care providers, patients and families to assist with difficult treatment (and non-treatment) decisions.

“A minority of DSD cases are able to receive a genetic diagnosis today,” he points out. “But geneticists know how important it is to come to a diagnosis and so we seek to increase the number of patients who receive a concrete genetic diagnosis. It impacts genetic counseling and reproductive options, and provides a better ability to predict long term outcomes.”

“These differences impact physiology and medicine. We want to better understand the biology of reproduction, with an emphasis on finding ways to preserve fertility at all costs, and how these variations may lead to additional complications, including cancer risk.”

At conception, he explains, both XX and XY embryos have bipotential gonads capable of differentiating into a testis or an ovary, though embryos are virtually indistinguishable from a gender perspective up until six weeks in utero.

Whether or not a bipotential gonad forms is largely left up to the genetic makeup of the individual. For example, a gene in the Y chromosome (SRY) triggers a cascade of genes that lead to testis development. If there is no Y chromosome, it triggers a series of pro-female genes that lead to ovarian development.

Dr. Vilain notes that a variation of enzymes or transcription factors can occur at any single step of sex development and alter all the subsequent steps. Depending on the genotype, an individual may experience normal gonadal development, but abnormal development of the genitalia, for example.

He also noted that these genes are critical to determining the differences between men and women in non-gonadal tissues, including differences in gene expression within the brain. One study in the lab of investigator Matt Bramble, Ph.D., investigates if gonadal hormones impact sex differences in the brain by modifying the genome.

This work is a prime example of research informing the care provided to patients and families. Dr. Vilain is also a member of the multidisciplinary clinical team of the PROUD Clinic at Children’s National, a program completely devoted to caring for patients with a wide array of genetic and endocrine issues, including urogenital disorders and variations of sex development.

Love is in the air and, for parasites, inside our bodies

Michael H. Hsieh

As featured in a PBS video, schistosome worms form lifelong bonds and females produce thousands of eggs daily only when they live inside human hosts, says Michael H. Hsieh, M.D., Ph.D.

“Love is in the air, the sea, the earth and all over and inside our bodies,” the PBS Valentine’s Day-themed video begins. As the public television station notes, what humans consider romance can look vastly different for creatures big and small, including serenading mice, spiders who wrap their gifts in silk and necking giraffes.

The “spooning” parasites segment of the video is where viewers see research conducted by Michael H. Hsieh, M.D., Ph.D., director of the Clinic for Adolescent and Adult PedIatric OnseT UroLogy at Children’s National Health System, and video filmed in his lab.

Schistosomiasis, a chronic infection with schistosome worms, is a distinctly one-sided love affair. As shown in Dr. Hsieh’s video clips, the male worm is shorter and fatter and equipped with a groove, a love canal where the longer, thinner female lodges, enabling the pair to mate for decades. This lifelong bond and the thousands of eggs it produces daily can only occur when the worms are inside the human host, Dr. Hsieh says.

While the video stresses Valentine’s Day romance, there are few rosy outcomes for humans who are the subject of the schistosome worms’ attention.

“Heavily and chronically infected individuals can have lots of problems,” Dr. Hsieh says. “This is a stunting and wasting health condition that prevents people from reaching their growth potential, impairs their academic performance and leaves them sapped of the energy needed to exercise or work. It truly perpetuates a cycle of poverty, particularly for affected children.”

Even the potential bright spot in this sobering story, the ability of the body’s immune system to fend off the parasitic worms, is only partly good news.

Schistosome worms have co-evolved with their human hosts, learning to take advantage of human vulnerabilities. Take the immune system. If it kicks too far into overdrive in trying to wall off the eggs from the rest of the body, it can interfere with organ function and trigger liver failure, kidney failure and early onset of bladder cancer, he says.

However, Dr. Hsieh and other schistosomiasis researchers are working on ways to positively harness the human immune response to schistosome worms, including developing diagnostics, drugs and vaccines. He says he and his colleagues would “love” to eliminate schistosomiasis as a global scourge.

Twitter Pediatric Urology Journal Club @pedurojc

Journal club, with a 140-character limit

Twitter Pediatric Urology Journal Club @pedurojc

@perforin & @chrbayne have launched a new journal club focused on pediatric urology via Twitter, a platform that democratizes and distills the academic discussion.

Journal club is a rite of passage for nearly everyone who works in an academic laboratory. What might sound like an exclusive group of readers and authors united by a secret handshake is actually a regular meeting of scientists – faculty members and young trainees alike – who gather to discuss a highlighted paper in their field of expertise.

Some of these gatherings might involve a handful of people from the same lab; others might include a larger group from the same institutional department or division. Typically, one person presents a paper, sharing all the relevant details about a study’s methodology and conclusions. Afterward, everyone has the chance to pose questions, make comments and thoroughly discuss conclusions.

“It’s an excellent academic opportunity in terms of teaching and training of early career scientists and clinicians, and it remains useful no matter what stage you are in your career,” says Michael Hsieh, M.D., Ph.D., a urologist who directs the Clinic for Adolescent and Adult PedIatric OnseT UroLogy (CAPITUL) at Children’s National Health System who has participated in a heavy share of journal club meetings over the years.

But, what if journal club didn’t have to adhere to this traditional format? What if this academic discussion could move to a venue more fitting for the 21st century, more inclusive of scientists in different geographic locations, with varying viewpoints and expertise?

That’s what Dr. Hsieh and others are trying to accomplish with a new pediatric urology-focused journal club on Twitter. When Christopher Bayne, a second-year fellow training in pediatric urology at Children’s National under Dr. Hsieh’s mentorship, approached him with the idea, Dr. Hsieh said that he jumped at the chance.

Traditional journal clubs, the two explain, can be hindered by several factors. One is a tendency toward “group think,” Dr. Hsieh says – members of the same lab, or even the same institution, tend to have the same training and practices, so they’re less likely to feel comfortable introducing new ideas about these areas into the discussion. Journal club discussions also are limited by uncertainties about what a study author might have had in mind with their methodology and conclusions. Study authors are rarely included in the discussion, Dr. Hsieh adds.

Michael Hsieh

“It’s an excellent academic opportunity in terms of teaching and training of early career scientists and clinicians, and it remains useful no matter what stage you are in your career,” says Michael Hsieh, M.D., Ph.D., a urologist who directs the Clinic for Adolescent and Adult PedIatric OnseT UroLogy (CAPITUL) at Children’s National Health System.

Twitter, Bayne says, offers an easy way around these barriers. Rather than including just members of the same lab, their Pediatric Urology Journal Club (PUJC) can accommodate any registered Twitter user in their discussions. That means that any interested person around the world – researchers, clinician-scientists, other health care providers, as well as patients and their families, for example – can participate in the monthly discussions.

Participation also isn’t dictated by geography. During recent PUJC meetings, individuals joined the thread from Brazil, Ireland and Turkey. The meetings, sponsored by the Journal of Pediatric Urology, take place in the first days to weeks after the selected paper has been available under “open access,” giving anyone a chance to read it – even if they lack a journal subscription. This format enables all participants to join threads, erasing the restrictions of geography or busy clinical and research schedules.

Thus far, the meetings have included papers on:

  • A comparison of the cost and complications of performing a surgery either robotically or through an open procedure to fix the tubes that connect the kidneys to the bladder in patients with a condition known as vesicouretal reflux, in which urine flows in the wrong direction.
  • The pros and cons of treating varicoceles, enlarged veins inside the scrotum that potentially cause fertility problems. The condition is asymptomatic in adolescents.
  • The importance of the diameter of the ureter, the part of the tube closest to the outside of the body that carries urine to be expelled, for resolving vesicouretal reflux, an abnormal flow of urine.

This new platform has attracted a core group of relatively young and young-at-heart devotees, Bayne says. He and other organizers have included study authors in every meeting thus far, often guiding older and Twitter-naive scientists through the process of creating an account.

And the typical 140-character limit Twitter imposes on comments known as tweets? “It might be counterintuitive,” Bayne says, “but I see the character limit as one of this journal club’s biggest strengths.” This cutoff encourages discussion members to distill their thoughts, often including two or three distinct points, into concise and deeply meaningful statements. “Participants have really latched on to the efficiency of this approach to learning about a topic and having a lively discussion.”

Thus far, their approach has been increasing in popularity. Their very first PUJC meeting in February 2017 attracted a modest number of just 24 active participants who sent 310 tweets, but generated nearly 136,000 impressions, or views.

The researchers plan to continue the monthly PUJC meetings through the Twitter handle @pedurojc. You can follow updates from Dr. Hsieh on his handle: @perforin and updates from Bayne’s on his: @chrbayne.

Boy and Mom with Doctor

Straightening out testicular torsion care

Boy and Mom with Doctor

A new collaborative accelerated care pathway for testicular torsion assessment and treatment may save critical time between diagnosis and intervention.

The clock starts ticking for a child with testicular torsion as soon as the pain starts. To increase the likelihood of successfully salvaging the twisted testicle and spermatic cord, surgical intervention – which involves restoring blood flow to the testis – should ideally occur within six hours from the onset of pain.

That’s six hours for a parent to identify that there is a problem, bring a child to the emergency department (ED) and go through all the steps required to get the child to the operating room. This process starts with an emergency physician, who probably doesn’t see many cases of this relatively rare condition, being able to identify the potential issue and contact the pediatric urologist on call. Next, diagnostic imaging orders need to be placed and actual imaging needs to occur for the diagnosis to be made. Finally, the patient needs to be moved to the pre-operative area, assessed by the anesthesia team and then taken to surgery.

In April 2016, the Division of Urology at Children’s National launched a new, accelerated care pathway for testicular torsion assessment and treatment that was developed collaboratively with the Emergency Department, Diagnostic Imaging and Radiology, the Department of Anesthesiology, and the peri-operative and operating room team.

“What stood out to us when we looked at the total time from identifying the problem to getting to surgery, was the length of time from when the diagnosis was made in the emergency department to the operating room,” says Tanya Davis, M.D., a pediatric urologist who led this new initiative along with Harry Rushton, Jr., M.D., chief of the Division of Urology. “It was an area where we could easily identify and streamline the process to accelerate the time for a patient to get from arrival in the ED to the surgical suite.”

Now, when a patient presents in the emergency department with the symptoms of testicular torsion, there is a straightforward path mapped out for the physician. “Who you need to talk to, how to reach them, relevant phone numbers, details on when to communicate to the attending physician, the ideal order of activities, the ability for residents to quickly transport the patient rather than waiting for hospital transport to surgery, and, most important, making it clear to everyone involved that this condition is a true emergency when every second matters,” Dr. Davis adds.

Torsion ED to OR Graph

Analysis of the streamlined care pathway, which emphasizes communication that the condition is a true emergency, has improved time from ED to OR within target ranges.

Since the initiative’s launch, 21 cases, from referrals and direct diagnosis, have come into the ED. The new protocol is working efficiently, reducing the mean time from the ED to the OR by more than an hour, now averaging below the team’s target goal of less than 2.5 hours from ED arrival to the OR.

Though salvage rates have not improved yet, the team will continue to collect data and monitor the impact of the accelerated pathway. Additionally, Dr. Davis says that a significant need remains for referring emergency and primary care physicians, as well as parents, to understand the condition and its need for urgent treatment. Children’s National urologists are developing handouts for both physicians and families to help raise awareness.

The hope is that more general knowledge of testicular torsion will allow parents, primary care doctors and emergency department staff to expedite diagnosis when a child complains of scrotal pain or has visible discoloration, further reducing the time from onset of pain to successful intervention. With such a short window of time for treatment, the accelerated care pathway is showing promising results.

Research finalist: targeted ultrasound of the tibial nerve can affect bladder function

Daniel Casella, M.D,, wants to design a bracelet that uses ultrasound waves to stimulate the posterior tibial nerve in pediatric patients with overactive and underactive bladders. “Realistically and optimistically, we might be five years away from that,” says Dr. Casella, a pediatric urologist at Children’s National Health System who has been studying the ability of ultrasound mediated neuromodulation of the posterior tibial nerve to affect bladder function. For this work, he was named a research finalist at the Pediatric Urology Fall Congress in September.

Up to 40 percent of patients seen in a pediatric urology clinic have an element of voiding dysfunction. The majority of these patients can be managed with behavior modification and conservative measures; however there is a subset of these patients who will require more aggressive therapy. With the possibilities that this research holds, he suggests ultrasound mediated tibial nerve stimulation as potentially an ideal outpatient treatment of overactive bladder and dysfunctional elimination.

What we know

The S3 sacral nerve root contains neurons that play an important role in regulating bladder function. Stimulation of the S3 nerve root with a surgically placed neurostimulator is an effective treatment for overactive or underactive bladders in adults and more recently pediatric patients. The problem: Placement of the S3 nerve stimulator is an invasive surgical procedure that requires revision or additional procedures in up to 50 percent of pediatric patients.

Another treatment: Stimulation of the posterior tibial nerve (a peripheral extension of the S3 nerve root), with an electrical current is also an effective treatment of both overactive and underactive bladders. The problem: For a durable response, the posterior tibial nerve must be stimulated with an electrical current that produces a moderate level of discomfort for 30 minutes. These treatment sessions must then be repeated weekly for approximately 12 weeks, making it very difficult to offer this therapy to pediatric patients.

New hope for patients with bladder dysfunction

Using targeted ultrasound to stimulate nerves is an area of active research within the radiology and neuroscience community. To date, studies in humans are limited, however there have been promising results when transcranial ultrasound was used to stimulate the deep brain motor centers, potentially offering a novel treatment for movement disorders such as Parkinson’s.

Dr. Casella started this research during his pediatric fellowship at Vanderbilt with the support of a $25,000 grant from the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction.

Dr. Casella says: “Using an established model of bladder overactivity in rats, we demonstrated that 2-3 minutes of ultrasound stimulation of the posterior tibial nerve can suppress bladder contractions for an average of 10 minutes.”

What’s next?

Dr. Casella plans to refine his techniques in animal models and work toward designing an ultrasound probe that can be used in humans. He is hopeful that his protocol will be ready for application in a clinical trial in the next one to two years. “Ultimately our goal is to design something that can be used at home,” Dr. Casella says. Ultrasound devices can be more compact if imaging isn’t the primary use. Ideally we would like to have the ultrasound transducer in the form of an ankle bracelet attached to a generator similar in size to a smartphone.

watch

Cryopreservation of testicular tissue gives cancer patients fertility hope

stocksnap_u4eob3qn5x

One of the most common causes of premature death is cancer. But today, survival rates for many childhood cancers have surpassed 90 percent and the emphasis of care has shifted from survival to quality of life after survival. That’s according to Michael Hsieh, M.D., Ph.D., who is leading the program at Children’s National Health System and getting much support from oncology and neonatology.

“One of the important aspects of quality of life is fertility,” Dr. Hsieh says. “For those adult survivors of childhood cancer who want to have children, I think it’s imperative that we do whatever we can to help them.”

The program at Children’s National, part of a multi-institutional consortium based at the University of Pittsburgh, had one of the highest recruitment of all the satellite sites for this study, which offers cryopreservation of boys’ testicular tissue. From Dr. Hsieh’s program, tissue from 11 patients has been harvested in a year and a half.

Radiation and chemotherapy are toxic to the gonads, which have testicular and ovarian function. “The idea is that if we can freeze the testicular tissue until the technology catches up in such that we can restore fertility down the road, that’s a wonderful thing. Most of these children are in grade school and not interested in having children until at least 15-20 years.”

Getting the tissue samples

For the first time, parents of young cancer patients are having this discussion, and Hsieh says they are extremely appreciative, even if they decline to participate in the study.

Young men can provide a sperm sample, which can easily be frozen. For boys who haven’t gone through puberty or boys who are not able to give a sample because they are too sick or unwilling to do so, a biopsy can collect a tissue sample, which can then be frozen.

Storing samples at a cost

Hsieh says his work also is focused on improving funding for storage of tissues. The out-of-pocket costs to store samples are several hundred dollars a year, and it can be cost-prohibitive for some patients and families.

Hsieh has applied for financial assistance from Children’s National internal funding opportunities for the program to help even the playing field.

“I don’t think it’s fair that a child who is born into a poor family is unable to participate in fertility preservation whereas a child who happens to be born more affluent is able to,” Hsieh says.

bridge

Transitional urology bridges care for those with pediatric-onset conditions

bridging

A hot topic at national urology meetings is how to transition patients with pediatric-onset urologic conditions as they grow into adults. Michael Hsieh, MD, PhD, is leading the way in the U.S. by serving as a bridge for patients at the first dedicated transitional urology program in the mid-Atlantic region. The Clinic for Adolescent and Adult PedIatric OnseT UroLogy (CAPITUL) is a joint venture between Children’s National and George Washington University Hospital that started two years ago.

What’s most unique about the clinic is that Dr. Hsieh has a foot in both the pediatric world of urology and one in the adult world, with clinical privileges at both institutions. He sees the full span of pediatric urology patients, including expectant moms with fetuses that have suspected urologic anomalies to adults who may have congenital conditions that require follow-up. However, he sees more teenagers and young adults than his urology colleagues both at hospitals.

The clinic’s patients have included a 19-year-old man with multiple urethrocutaneous fistulas after failed hypospadias repairs, a 25-year-old woman with cloacal exstrophy and continent urinary diversion with a urinary tract infection and stones, and a 25-year-old man with spina bifida with incontinence urethral erosion from an indwelling catheter.

A number of significant urological conditions until recently led to premature death because of medical complications, Dr. Hsieh says. Today, 90 percent of spina bifida patients live past the age of 30. “There’s a synchronized wave of patients who are all now young adults with spina bifida, and they are facing issues of reproduction and sexuality,” Dr. Hsieh says. “These are issues that pediatric urologists generally speaking are not comfortable in managing. It makes sense: It’s been many, many years since they did that type of urology.”

The program is specifically following this transitional group on conditions that are long term and that may affect fertility, such as cancer and varicoceles.

One in five teenage boys have varicoceles, or varicose veins on the scrotum. “The relationship between having varicocele as a teenager and infertility as an adult is not clear, so we felt it important to include this diagnosis in the transitional program so we can follow these patients long term and monitor their testicular growth,” Dr. Hsieh says.

Proof that the program’s working

Dr. Hsieh tracks the messages from colleagues referring patients from one institution to the other. “Unfortunately, some patients and families—for a range of issues—fall through the cracks, so it is really important to have that direct link. If we didn’t have the program set up as it is, there would be fewer successful transitions between institutions,” he says.

Another way Dr. Hsieh knows the program is working is because of the uptick in adolescent and young adult patients in his practices at Children’s and at GW.

Dr. Hsieh says the optimal time to begin transition is at age 12, when the team makes the patient and family aware of the transition policy. From ages 14-16, it’s time to initiate the health care transition plan and begin discussing the adult model of care. By age 18, Dr. Hsieh recommends the transition to adult care, and by ages 23-26, patients are integrated into adult care.