In This Issue
Research Spotlight:
New Pilot Grant Awards
CPCE In the News:
COVID-19 News
CPCE In the News:
Top Articles in Pediatric Hospital Medicine: July 2019 to June 2020
CPCE In the News:
Gas Flaring and Preterm Births
CPCE In the News:
State Regulation for the Development of Pediatric-Specific Protocols for Sepsis: Does it Work?
Upcoming Events
Recent Publications
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We are pleased to announce new projects awarded in the spring 2020 competition for the CPCE / PolicyLab Pilot Grant program.
Wlliam R. Otto, MD, has received a grant for his project, “Impact of Platelet Level on Risk of Bacteremia in Children Hospitalized for Treatment of Acute Myeloid Leukemia.” Dr. Otto will collaborate with
Brian T. Fisher, DO, MPH, MSCE,
Richard Aplenc, MD, PhD, MSCE, and Yimei Li, PhD. Children treated for acute myeloid leukemia (AML) are at risk for adverse effects, including bloodstream infections. Some of this risk may be attributable to a low level of platelets. However, there is little existing research on the variability of platelet count or the associated risk of bloodstream infection in these patients. The team aims to address this gap with a retrospective cohort study of a large, multicenter database of patients treated for AML. Results will inform clinical practice around platelet transfusion and guide the development of future clinical trials.
Beth Rutstein, MD, has received a grant for her project, “Incidence of Herpes Zoster in the Pediatric Autoimmune/Autoinflammatory Population.” Dr. Rutstein will collaborate with
Jeffrey Gerber, MD, PhD,
Sabrina Gmuca, MD, MSCE, and Alexis Ogdie-Beatty, MD, MSCE. Although incidence of herpes zoster (HZ, commonly known as shingles) has declined since the introduction of the chicken pox vaccine, HZ remains relatively common in autoimmune/autoinflammatory (AI) populations. Adult studies have led to changes in guidelines for AI patients regarding HZ vaccination; however, there are few studies in the pediatric population. This project will use retrospective chart review and healthcare claims data to better understand the risk for HZ infection in the pediatric AI community. The results will provide a foundation for studies that will identify opportunities to employ preventative measures to decrease HZ-associated morbidity.
Two additional projects were awarded by our PolicyLab colleagues:
- Jennifer Mautone, PhD, ABPP, and Jami Young, PhD, for their project “Brief, Evidence-based Psychotherapy in Integrated Primary Care: Pilot of FIRST.” The team seeks to test the feasibility and acceptability of a recently developed treatment known as FIRST, derived from components of evidence-based psychotherapies, when delivered at Healthy Minds, Healthy Kids (HMHK)—an integrated behavioral health program in CHOP primary care practices.
- Robin Ortiz, MD, Atheendar Venkataramani, MD, PhD, Courtney Boen, PhD, MPH, Diana Montoya-Williams, MD, and Katherine Yun, MD, MHS, for their project “Toward Understanding the Political Determinants of Health: An Analysis of the Impacts of Sanctuary Immigration Policies on Latinx Birth Outcomes.” The team seeks to map and describe sanctuary areas as they relate to Latinx communities and assess whether they are associated with improved birth outcomes—such as lower rates of preterm births and low birth weight—in Latina women.
Learn more about our pilot grant program awardees at
CPCE's and
PolicyLab’s websites.
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COVID-19 News
CPCE Core Faculty continue to study the transmission and impact of COVID-19. Stay up to date via the new
COVID-19 News page on our website. Here’s the latest:
A
study conducted by CHOP and Penn researchers looked at antibodies to COVID-19 as a marker of exposure among pregnant women in Philadelphia. They found exposure in 6.2 percent of women overall, but with significant variation across racial and ethnic groups: 9.7 percent in Black women, 10.4 percent in Hispanic/Latina women, 2 percent in White/non-Hispanic women, and 0.9 percent in Asian women. The study team included
Dustin Flannery, DO, MSCE,
Miren Dhudasia, MPH,
Sagori Mukhopadhyay, MD, MMSc,
Jeffrey Gerber, MD, PhD, and
Karen Puopolo, MD, PhD.
Last week, the
American Academy of Pediatrics updated guidance for care of infants born to mothers with COVID-19. Evidence now suggests that babies are at low risk of becoming infected when they remain in-room with the mother after birth, if infection control practices are used. Prior AAP guidance recommended temporarily separating babies from infected mothers. Dr. Puopolo is senior author of these guidelines. Read more from
CNN and
Science News.
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Top Articles in Pediatric Hospital Medicine: July 2019 to June 2020
At the
Pediatric Hospital Medicine 2020 Virtual Conference earlier this month, a
paper by
Christopher Bonafide, MD, MSCE and colleagues was named one of the Top 10 in the field of Pediatric Hospital Medicine for the 2019-2020 academic year. As we reported in the
May 8, 2020 issue of CPCE E-News, U.S. national guidelines discourage the use of continuous pulse oximetry to measure blood oxygen levels in infants with bronchiolitis who do not require supplemental oxygen. Despite these guidelines, Dr. Bonafide’s top 10 paper identified continuous pulse oximetry monitoring use in 46% of patients overall, with considerable variation by hospital and by risk condition.The
Top 10 review drew from nearly 12,000 articles.
“Our inclusion in the top 10 articles for the field this year represents a widespread recognition of the downstream problems that can occur when a medical technology — in our case pulse oximetry monitoring in stable infants with bronchiolitis — is overused,” Dr. Bonafide said in a CHOP Research Institute
Cornerstone blog post. “It will also help to further ignite national efforts to de-implement unnecessary monitoring in populations for which the downsides appear to outweigh the benefits.”
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Gas Flaring and Preterm Births
A recent study conducted outside of CHOP found that pregnant women who live near areas where gas flaring is common have 50 percent greater odds of giving birth prematurely than those who do not, possibly due to particulate matter, volatile organic compounds, and other toxic substances given off by the flares. CPCE Core Faculty member
Heather Burris, MD, MPH commented in The New York Times that these results add to growing evidence that environmental factors play an important role in the risk of prematurity.
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State Regulation for the Development of Pediatric-Specific Protocols for Sepsis: Does it Work?
In our
last issue of CPCE E-News, we reported on a new trial to compare effectiveness of fluids for sepsis treatment in pediatric patients, co-led by CPCE Core Faculty member
Fran Balamuth, MD, PhD.
Another sepsis-related study conducted outside of CHOP compared outcomes of sepsis in pediatric patients in New York State, which introduced regulations in 2013 mandating that hospitals develop pediatric-specific protocols for sepsis recognition and treatment, vs. patients in three control states without similar regulations. Over the four years studied, similar rates of decrease in sepsis mortality were seen in all states in the analysis. However, when metropolitan New York City hospitals were excluded, New York State showed greater improvement in sepsis mortality reduction. Dr. Balamuth and colleagues help to explain these results in
an invited commentary. Mortality improvement was most pronounced in general hospitals with small to medium pediatric volumes, suggesting that “the greatest impact of state regulation may be at the margins.” Other factors may have contributed to the overall improvement. “Improved care for pediatric sepsis is the ultimate goal, and this may be achievable by broad commitments to implement protocolized sepsis care for children, either with or without accompanying legislative changes,” Dr. Balamuth and colleagues conclude.
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Upcoming Events
Embracing Anti-Racist Approaches and Centering Race and Racism in the Life Course Research Agenda
Date: August 6, 2020
Time: 12:00 noon - 1:30 pm EDT
Poverty, race, culture, religion, or zip code should not determine a child’s trajectory, opportunity, and eventual life success. Often times, there is a focus on disparities and gaps between and among people with little consideration for root causes. Furthermore, there has been an assumption that “science” is objective and rooted in truthfulness. This session from the Life Course Intervention Research Network , we will begin to examine what is racism and the necessity of research to focus on the manifestation of racism and the critical importance of a racial equity research agenda to reach racial justice. Discussion will focus on how research can be re-centered to focus on race and racism and lean into critical race theory methodological approaches to create and sustain an anti-racist research agenda. Iheoma U. Iruka, Ph.D., is the Chief Research Innovation Officer and Director of The Center for Early Education Research and Evaluation at HighScope Educational Research Foundation after tenure at FPG Child Development Institute at the University of North Carolina-Chapel Hill and the Buffett Institute at the University of Nebraska. Learn more and register
here.
CPCE/PolicyLab Virtual Seminar Series*
Date: August 7, 2020
Time: 12:00 noon - 1:00 pm
*For CPCE/PolicyLab Virtual Seminar Series: If you would like to participate in any of the virtual events and did not receive a BlueJeans link, please contact
crosss2@email.chop.edu
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Recent Publications
Bronchopulmonary dysplasia is a common disease of prematurity that presents along a wide spectrum of disease severity. Researchers including
Nicolas Bamat, MD, MSCE describe their approach to the evaluation of infants with severe bronchopulmonary dysplasia. Important considerations include the phenotypic heterogeneity in clinical presentation that necessitates individualized care, the common presence of comorbidities and the importance of a comprehensive multisystem evaluation, and the value of applying a chronic care model that prioritizes long-term respiratory and neurodevelopmental goals.
Additional work by
Nicolas Bamat, MD, MSCE and colleagues reviews challenges to individualized approaches to medication use for severe pronchopulmonary dysplasia (sBPD) and explores the reasons for the variable responsiveness of infants to specific therapies, based on current understanding of developmental pharmacology and pharmcogenetics. This review also presents data demonstrating variability in the use of commonly prescribed drugs for sBPS, a discussion about the current use of some of these medications, and the potential use of antifibrotic medications in late-stage sBPD.
Jennifer Walter, MD, PhD, MS and colleagues wrote an editorial on the importance of research in advancing knowledge in the COVID-19 era. They make a case for the role of bioethicists and suggest a number of ways empirical bioethics researchers can contribute to the conversations about COVID-19, such as descriptive studies defining current practices, opinions, and policies to inform future research as well as the design of potential interventions aimed at improving care; assessment of the extent to which actual clinical practice reflects our purported ethical norms; and addressing questions about the ethical responsibilities of citizens, among others.
At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship is needed to improve prescribing and address the threat of antibiotic resistance.
Jeffrey Gerber, MD, PhD, MSCE and colleagues ran eight focus groups with primary care physicians (PCP) in four US cities to assess their current attitudes towards antibiotic resistance, inappropriate antibiotic prescribing, and the feasibility of outpatient stewardship efforts. Participants acknowledged that resistance is an important public health issue, but not as important as other pressing problems. Many considered resistance to be more of a hospital issue. Many felt inappropriate prescribing is driven more by non-primary care settings and patient demand.
In another study,
Jeffrey Gerber, MD, PhD, MSCE and colleagues sought to characterize the current state of antifungal stewardship practices and perceptions of antifungal use via an electronic survey distributed to pediatric antimicrobial stewardship programs (ASPs). Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals.
In 2011, the American Academy of Pediatrics (AAP) and NHLBI recommended universal cholesterol testing at age 9 to 11 years, discussing 2 rationales, 1) the identification of familial hypercholesterolemia and 2) the identification of less severe dyslipidemias associated with pediatric obesity that may represent a modifiable risk for cardiovascular disease. Researchers including
Emily Gregory, MD, MHS,
Robert Grundmeier, MD,
David Rubin, MD, MSCE,
Alexander Fiks, MD, MSCE ran a retrospective cohort study to ask whether, and to what extent, universal testing as been adopted since the 2011 guideline.
Cardiorespiratory and pulse oximetry monitoring in children who are hospitalized should balance benefits of detecting deterioration with potential harms of alarm fatigue.
Christopher Bonafide, MD, MSCE and his team developed recommendations for monitoring outside of the ICU on the basis of available evidence and expert opinion. Their expert panel members agreed that intermittent vital sign assessment, rather than continuous monitoring, is appropriate management for a set of specific conditions of mild or moderate severity that require hospitalization.
Research has demonstrated that most pediatric providers believe collective advocacy and political involvement are essential aspects of their profession, but less is known about how pediatric providers engage with families about policy issues that impact child health. A team including
Chén Kenyon, MD, MSHP ran a cross-sectional mixed methods study to examine providers’ perceptions and practices with regards to discussing health policy issues with families and to identify provider characteristics associated with having these discussions. Pediatric providers felt it was important to talk to families about child health policy issues, but few providers reported having such conversations in practice.
Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization.
Michael O’Byrne, MD, MSCE,
Joyce Chang, MD, MSCE, J
oseph W. Rossano, MD, MS, and colleagues conducted a retrospective cohort study with de-identified commercial insurance claims data to measure resource utilization, specifically cost and length of stay, which provides an integrated measure of morbidity not appreciable in traditional outcomes. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization after hospital discharge. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each.
In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers.
Joseph W. Rossano, MD, MS and colleagues designed a multidisciplinary quality improvement project to standardize perioperative management in a high volume cardiac center. This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2.
Exercise rehabilitation during pediatric ventricular assist device (VAD) support aims to improve musculoskeletal strengthening while awaiting heart transplantation (HT). Researchers including
Joseph W. Rossano, MD, MS ran a single-center cohort study to determine whether increasing VAD pump speed during exercise testing and training improves exercise capacity. Increasing VAD pump speed during exercise training results in substantial improvement in both physical working and aerobic capacity compared a fixed pump speed in children on VAD support regardless of single or biventricular ventricle physiology.
US News & World Report (USNWR) rankings can assist patients with choosing where to receive their specialty care. USNWR methodology assumes that the specialty caring for hospitalized patients is equivalent to the specialty assigned by administrative coding. A team including
Gregory Tasian, MD, MSc, MSCE examined the frequency of discordance between USNWR methodology-assigned specialty and the actual specialty care received for 2 surgical specialties, otolaryngology (ENT) and urology (GU). Their work identified a significant discordance between USNWR-assigned specialty and the actual specialty care received.
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About CPCE
We are a pediatric research center dedicated to discovering and sharing knowledge about best practices in pediatric care by facilitating, organizing and centralizing the performance of clinical effectiveness research -- research aimed at understanding the best ways to prevent, diagnose and treat diseases in children. CPCE’s multidisciplinary team conducts research on a diverse range of clinical effectiveness topics.
CPCE E-News is edited by
Holly Burnside. Please feel free to contact us with questions or feedback.
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