Jul 02 2015

Study Finds Gender Bias in Growth Hormone Treatment for Height

growth hormoneResearchers from The Children’s Hospital of Philadelphia have found a clear-cut and persistent gender bias in the provision of treatment for idiopathic short stature (ISS) with recombinant human growth hormone treatment. The work, which was published recently in Scientific Reports, shows short boys are three times more likely than short girls to receive recombinant human growth hormone treatment for ISS.

The statistical definition for ISS (short stature from an unknown cause) height corresponds to the shortest 1.2 percent of the U.S. population. The study aims at understanding the origins of the disparities in the management of short stature.

“Social pressures regarding height seem to affect males more than females, at least in the U.S.,” said the study’s leader Adda Grimberg, MD, a pediatric endocrinologist at Children’s Hospital and a senior fellow of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “In the absence of an underlying condition, treating short children with recombinant human growth hormone represents medicalization of a physical trait.”

The research team looked at the health records from 28 primary care practices in the CHOP pediatric network, comprising 189,280 patients, and compared them to 93,736 patients from the four U.S. pediatric growth hormone registries. All the subjects were children and adolescents (up to age 20).

In the primary care population, 2,073 subjects (1.1 percent of the total) had heights below the threshold for idiopathic short stature. There were no gender differences in the prevalence of height below this threshold, or in the distributions of height in the entire primary care population.

In contrast, among patients receiving recombinant human growth hormone for ISS, 74 percent were male. Among patients who received the hormone for all diagnoses, 66 percent were male. At the time of initiating growth hormone for idiopathic short stature, treated boys outnumbered girls for every year of age starting at age one, but the biggest differences occurred around puberty, when late bloomers and limited remaining time for potential medical intervention raise concern.

“Growth is an important sign of child health, so growth failure merits equal consideration for both boys and girls,” Dr. Grimberg said. “Gender bias in treatment may have doubly undesirable effects — short girls who have an underlying disease may be overlooked, while short healthy boys may receive overzealous, unnecessary treatment with an expensive drug that requires years of nightly injections and has potential side effects.”

Human growth hormone treatment costs roughly $20,000 per child per year, and requires daily injections.

In previous research, Dr. Grimberg found that proportionally more girls who were referred for evaluation of short stature were much more likely to have an underlying disease than boys who were referred. “The gender bias in referral and treatment suggests that diagnoses of underlying diseases are more likely to be delayed or missed altogether in short girls, and this suggests missed opportunities to address those conditions, not all of which require growth hormone treatment,” she said.

For more information, and for a link to the study in Scientific Reports, published online June 9, 2015, click here.

Permanent link to this article: http://blog.research.chop.edu/study-finds-gender-bias-in-growth-hormone-treatment-for-height/

Jul 01 2015

International Partnership Leads to Cerebral Palsy Insights

cerebral palsyThe most common cause of childhood disability in the world, cerebral palsy affects between 1 and 2 infants per thousand. But despite its prevalence, this neurological condition — which can cause a variety of movement issues and other challenges — tends to be understudied, especially in developing countries.

However, a new study from The Children’s Hospital of Philadelphia sheds light on CP’s impact. Based on an ongoing partnership in Botswana with the University of Pennsylvania, pediatric researchers in Children’s Hospital’s Global Health Center performed the first rigorous study of CP outcomes in Africa. In this and related studies, they summarized the scope and overall public health challenges CP presents in this low-resource setting.

“For a variety of reasons, children with cerebral palsy tend to have poorer outcomes and a higher prevalence of comorbidities in Botswana compared to those in higher-resource countries,” said study leader David Bearden, MD, a pediatric neurologist at CHOP. “Our research represents a first step toward designing better prevention and treatment of CP in settings such as Botswana.”

Dr. Bearden and his team presented their findings recently at the American Academy of Neurology annual meeting last month in Washington, D.C. The Academy selected one of the investigators’ studies for the “highlights in the field” session.

CP encompasses a variety of motor dysfunctions resulting from brain injury during the fetal period, infancy, or early childhood. Patients with this lifelong condition often have poor muscle control and speech problems.

In their study cohort of 68 children with CP at a referral center in Gaborone, Botswana, Dr. Bearden and colleagues found the most common causes of the condition were prematurity, intrapartum hypoxic events (periods of low oxygen during labor or birth), and infections during infancy. Severe motor impairments were common, with the most severe category occurring in 42 percent of the patients. In the U.S. and European studies, less than 20 percent of children with CP are in the most severe category.

The participants in the study also had high rates of comorbidities, or accompanying conditions. The most predominant was cognitive impairment, found in 83.8 percent of the children, followed by epilepsy (76.5 percent), and visual impairment (45.6 percent). These rates of epilepsy and cognitive impairment were more than double the rates reported in studies of CP in high-resource settings.

When parents and caregivers were interviewed about health beliefs, cultural values, and other barriers to care for children with CP, they expressed major concerns about lack of access to physical therapy, adaptive medical equipment, and good nutrition.

For Dr. Bearden, who has participated in the Botswana/Upenn Partnership since 2007, spending 2 to 3 months there every year, the current studies provide a foundation for further medical work, both in improving health education and devising better public health interventions.

“We need to work closely with doctors in low-resource settings to develop low-cost interventions for children with cerebral palsy,” Dr. Bearden said.

“For example, a community-based rehabilitation approach, teaching parents basic rehabilitation techniques, combined with regular check-ins by a community health worker in the family’s home, is much more likely to succeed that an approach that depends on parents regularly bringing children to the hospital for therapies,” he noted.

To learn more about cerebral palsy care at The Children’s Hospital of Philadelphia, see the Cerebal Palsy Program website. And for more information about CHOP’s global health work, see the Global Health Center.

Permanent link to this article: http://blog.research.chop.edu/international-partnership-leads-to-cerebral-palsy-insights/

Jun 30 2015

Researchers Pinpoint Mutations in Relapsed Neuroblastoma

neuroblastomaAn international collaboration of researchers has identified several progressive series of mutations that occur in tumor cells responsible for aggressive subsets of neuroblastoma that relapse after chemotherapy. Neuroblastoma, a solid tumor of nerve tissue, is the most common cancer in infants, and its cure rates lag behind those for other pediatric cancers.

The investigators, including co-study leader Derek Oldridge from the lab of John M. Maris, MD, at The Children’s Hospital of Philadelphia, performed extensive genetic sequencing of 23 pairs of tumors obtained at initial diagnosis and at relapse from the same patients. This allowed the researchers to compare the tumors’ genetic and molecular characteristics. Among the 23 relapsed tumors, 18 harbored mutations that boosted signals funneling into a biological pathway called RAS-MAPK, which made neuroblastoma progress.

“Our results imply that a clonal selection process occurred — meaning that more aggressive, cancer-driving mutations acquired a selective advantage after chemotherapy, leading to relapse,” Oldridge said.

Clonal selection is a process by which mutations allow malignant cells’ descendants to become more dominant. For example, a mutation that enables a cell to grow and divide rapidly could give it a head start at relapse compared to other cells within the tumor population.

The researchers published their results in Nature Genetics, demonstrating that relapsed neuroblastomas show frequent RAS-MAPK pathway mutations. Their findings offer new prospects to design personalized treatments for children with neuroblastoma. A group of drugs called MEK inhibitors that target those cancer-driving mutations are already available. Previous research in cell cultures and animal studies has shown that MEK inhibitors slowed tumor growth and improved the animals’ survival.

“Our preclinical findings strongly suggest that MEK inhibitors may directly benefit patients who suffer a relapse and have mutations in the RAS-MAPK pathway,” said Dr. Maris, a pediatric oncologist at The Children’s Hospital of Philadelphia who holds the Giulio D’Angio Chair in Neuroblastoma Research. “We think one of the most important conclusions from this work is that we should completely change our approach to relapsed disease. Until now, tumor biopsy was not necessary at relapse as it was very unlikely to change clinical practice. Now that we know that sequencing these resistant cancers can nominate novel therapies, we think we are entering a new era of personalized therapeutic decision making for children with currently incurable disease.”

It is likely that other biological pathways also contribute to the high risk of treatment failure in certain neuroblastoma cases. Dr. Maris recently received a new grant from the National Cancer Institute to investigate the role of the LMO1 gene locus in the initiation, growth, and survival of neuroblastoma, building on his lab’s discovery of LMO1 as a major oncogene in this disease. Greater understanding of key cellular networks such as RAS-MAPK and LMO1 will help researchers to develop rational, evidence-based strategies for precision medicine in neuroblastoma and other cancers.

In the U.S., about 800 new cases of neuroblastoma are diagnosed each year. It accounts for 7 percent of all childhood cancers, but it causes 15 percent of all childhood cancer deaths.

The study that appeared in Nature Genetics also involved Thomas F. Eleveld, MSci, and Jan J. Molenaar, PhD, of the Academic Medical Center of the University of Amsterdam; and Virginie Bernard, PhD, and Gudrun Schleiermacher, MD, PhD, of the Institut Curie in Paris. Funds from the National Cancer Institute, the Children’s Oncology Group, and the University of Pennsylvania Genome Frontiers Institute supported this study.


Permanent link to this article: http://blog.research.chop.edu/researchers-pinpoint-mutations-in-relapsed-neuroblastoma/

Jun 25 2015

Web-based Game Teaches Coping Strategies After Traumatic Event

Coping Coach

Coping Coach aims to prevent post-traumatic stress in school-aged children by using game-like activities that they can complete independently or with parent supervision.

Millions of children will likely experience some kind of unexpected traumatic event, from car crashes to natural disasters to medical emergencies. Many will struggle with psychological challenges during recovery, and parents and physicians may not know how to help them cope emotionally after such frightening episodes.

Researchers at The Children’s Hospital of Philadelphia have developed a web-based intervention called Coping Coach that aims to prevent post-traumatic stress in school-aged children by using game-like activities that they can complete independently or with parent supervision. The study team tested its feasibility in a randomized controlled trial of 72 children ages 8 to 12 who had been admitted to the hospital for an acute medical event. The investigators reported positive results in the Journal of Pediatric Psychology.

“It’s a different way of engaging kids,” said Nancy Kassam-Adams, PhD, a CHOP psychologist and associate director of Behavioral Research at the Center for Injury Research and Prevention (CIRP). “We’ve worked hard to build in items that are useful and therapeutic while keeping it fun. It doesn’t substitute for full-blown mental health treatment. This is for the early days after they’ve been through something difficult, and it teaches kids skills to recover well.”

The online tool starts with a short symptom assessment each time a child logs on. Then the child has the opportunity to interact with different characters, including a misunderstood squirrel named General Malaise. “Mwa-haha-haaaa!” he laughs, and then zaps the town, leaving the townspeople without any feelings. The child must identify different emotions in order to advance to the next module.

Coping Coach

The other modules also focus on areas that CIRP researchers and others have shown to be important in intervening early to lower the severity of pediatric post-traumatic stress. These include teaching children to recognize helpful or unhelpful thoughts and behaviors and how not to rely on avoidance as a coping response. An underlying theme that emphasizes the value of social support is embedded throughout the game.

“Each module includes carefully selected intervention targets based in empirical evidence on how post-traumatic stress develops in children,” said Meghan Marsac, PhD, a CHOP psychologist at CIRP, who has co-led the development and evaluation of Coping Coach. “We have applied what we know about the treatment of post-traumatic stress to prevention.”

A group of University of Pennsylvania digital media students created an early version of the game as a summer project five-years-ago and gave it a retro, pixelated vibe. A web design firm in Houston then came on board as collaborators and helped to expand the story and make the tool more robust and interactive. The CHOP Youth Advisory Council shared its feedback at various stages of the game’s development.

The latest version of Coping Coach includes a girl who experiences a scary asthma flare-up, a girl who has been in a car crash, a boy who survived a house fire, and a boy who saw his brother beaten up by other neighborhood kids. The game can be expanded to include other characters to address other sudden, distressing situations.

Coping Coach

“Children who use Coping Coach may not see their exact experience, but they get a sense of the range of common traumatic scenarios that kids are exposed to,” Dr. Kassam-Adams said.

For the study, the researchers invited one group of children to log in and play the game within six weeks after being admitted to the hospital. A second group was assigned to a wait list and given the same instructions to complete the online intervention activities following a 12-week research assessment. Both groups completed research assessments over the phone at 6, 12, and 18 weeks so that the researchers could track their symptoms and coping skills over time. They concluded that both groups benefited from Coping Coach participation, which suggests its recommended timing can be flexible.

“Depending on the nature of the event, and the child’s physical/medical condition, some children may not be ready or able to engage in an online intervention immediately post-event,” the authors wrote in their analysis.

Coping Coach

The next step is to test Coping Coach in a bigger trial, Dr. Kassam-Adams said. In the meantime, the research team is looking at ways to incorporate new features into the game to encourage children to play it longer and return again and again, perhaps reinforcing the coping strategies. About 60 percent of the children who participated in the study finished the game at least once, and they used it for an average of 52 minutes.

Coping Coach also received a pilot research grant from The Children’s Hospital of Philadelphia’s Violence Prevention Initiative to see how well it works for a group of 20 children who experienced a community-violence related injury.

“In our previous evaluation, we have focused on children exposed to unintentional traumatic events,” Dr. Marsac said. “We know that many children also have to deal with trauma resulting from violence, which can bring up unique feelings and challenges. This new research will allow us to examine whether or not the elements of Coping Coach can also be helpful for children experiencing injuries due to violence.”

Once the researchers have enough data to validate Coping Coach’s effectiveness, Dr. Kassam-Adams anticipates that it could be publicly available within the next five years. Since the number of school-aged children who could benefit from a low-cost, web-based post-traumatic stress intervention is enormous, she envisions Coping Coach as a way to fill the gap in resources available to support them during their recovery.

“It could have a huge public health impact on kids exposed to trauma,” Dr. Kassam-Adams said. “They can’t all get in — and not all need to get in — to see a mental health professional. Coping Coach is designed to be preventive. It has the potential to reach so many more kids that even if it helps a little, it will be an important tool.”

Permanent link to this article: http://blog.research.chop.edu/web-based-game-teaches-coping-strategies-after-traumatic-event/

Jun 24 2015

President Obama Appoints CHOP Oncologist to National Cancer Board

cancerPeter C. Adamson, MD, a pediatric oncologist and leading scientist at The Children’s Hospital of Philadelphia (CHOP), and a professor of Pediatrics and Pharmacology at the Perelman School of Medicine at the University of Pennsylvania, has been appointed by President Obama to the National Cancer Advisory Board (NCAB). Dr. Adamson is the only pediatric oncologist to currently serve on the NCAB, and will work to ensure the voices of the pediatric cancer community are heard by decision makers in the federal government.

In this role Dr. Adamson will advise the U.S. Secretary of Health and Human Services, the Director of the National Cancer Institute (NCI), and the President on a wide range of issues relating to the national cancer program including NCI operations. Notably, the NCAB and the President’s Cancer Panel are the only advisory bodies at either the National Institutes of Health or the Department of Health and Human Services whose members are appointed by the President.

“We are extremely proud of Dr. Adamson on his appointment by President Obama to this distinguished advisory board,” said Joseph St. Geme, MD, physician-in-chief and chair of the Department of Pediatrics. “This recognition is a testament to his dedication and leadership within the medical community in furthering research to advance treatment for childhood cancer.”

This appointment follows the President’s announcement in the State of the Union address of a Precision Medicine Initiative that will harness research and technology toward developing individualized treatments for many diseases.

An internationally recognized leader in pediatric cancer drug development, Dr. Adamson has served as Chair of The Children’s Oncology Group (COG), the world’s largest organization devoted exclusively to childhood and adolescent cancer research, since 2010. Through COG, he works with leading pediatric cancer researchers at CHOP and across the country who are hard at work on the most promising new therapies.

From 1999 to 2014, Dr. Adamson was Chief of the Division of Clinical Pharmacology and Therapeutics at CHOP, and he also served as Director of the Office of Clinical and Translational Research from 2005 to 2011. Prior to joining CHOP in 1999, he was a member of the Pediatric Oncology Branch of the NCI.

To read more about cancer care and research at The Children’s Hospital of Philadelphia, see the Cancer Center.

Permanent link to this article: http://blog.research.chop.edu/president-obama-appoints-chop-oncologist-to-national-cancer-board/

Jun 23 2015

No Difference in Outcomes for Premature Infants Enrolled in RCTs

premature infantsMany families of premature infants quickly become familiar with a powerful research tool called a randomized clinical trial (RCT). Neonatologists may invite them to participate in RCTs, as they investigate ways to help prevent, treat, and manage the myriad complications that can occur when these babies’ organs are not ready for life outside their mothers’ wombs.

In a RCT, study participants are randomly assigned to two or more groups, which helps to reduce any potential bias and compare research results. For example, one group receives a new drug being tested, and one group receives a placebo, no treatment, or a different drug. Parents, however, may wonder if the decision to include their newborns in a RCT could be associated with any detrimental differences in their outcomes.

A research letter published in JAMA by several neonatologists from The Children’s Hospital of Philadelphia and the University of Pennsylvania may help to alleviate these concerns. They reported results from a study of 5,000 extremely preterm infants and determined that important in-hospital outcomes, such as severe brain injury and a chronic lung disorder called bronchopulmonary dysplasia, were neither better nor worse in infants enrolled in RCTs compared with infants who were eligible but not enrolled in RCTs.

“These results are important, as they provide reassurance that participating in randomized trials is not detrimental to preterm infants,” said Elizabeth E. Foglia, MD, an attending neonatologist with the Division of Neonatology at CHOP, who co-authored the letter.

The new findings are in line with previous research of adults and older children that demonstrated no significant differences in outcomes between trial participants and nonparticipants who were treated similarly outside trials, the authors pointed out.

The researchers performed their analysis of trial enrollment and outcomes using data from six RCTs performed at National Institute of Child Health and Human Development Neonatal Research Network (NRN) sites between January 1999 and December 2012. All of the infants had outcomes recorded in the NRN’s very low-birth-weight registry.

“Many therapies that are commonly used in preterm and sick infants have never been rigorously tested, and novel interventions are being developed all the time,” said Dr. Foglia, who also is an instructor in Pediatrics at the Perelman School of Medicine, University of Pennsylvania. “The only way we can know with confidence that a given therapy is safe and effective in our patients is by performing well-designed and appropriately regulated randomized trials.”

Several RCTs involving premature infants are underway at The Children’s Hospital of Philadelphia, such as the Sustained Aeration of Infant Lungs Trial (SAIL) trial, which is looking at the standard of care for resuscitation of these babies at delivery. Another RCT is comparing two oral feeding schedules for premature infants, and researchers are collecting data on milk transfer, sucking strength, growth, and medical complications.

More information about making the decision to participate in a clinical trial is available in the Parents resources section of The Children’s Hospital of Philadelphia’s Research Institute’s website.

Read a press release for additional details about the JAMA research letter.

Permanent link to this article: http://blog.research.chop.edu/no-difference-in-outcomes-for-premature-infants-enrolled-in-rcts/

Jun 18 2015

Study Seeks to Treat Crohn’s Disease’s Effects on Growth, Bone Density

crohn's disease

A review published in the World Journal of Gastroenterology notes “growth failure and impaired nutritional status” are seen in 65 to 85 percent of young CD patients.

A study published in the Journal of Clinical Endicronology & Metabolism shows a drug approved to treat Crohn’s disease and ulcerative colitis leads to “rapid improvements” in bone density and structure. This investigation, which was conducted by former and current Children’s Hospital researchers, could offer Crohn’s disease patients a treatment for the growth and bone issues associated with the condition.

The study was led by Mary B. Leonard, MD, MSCE, while its first author was Lindsay M. Griffin, MD. Both Drs. Leonard and Griffin — now at Stanford University and New York University, respectively — were previously at The Children’s Hospital of Philadelphia, where the bulk of the work was performed. CHOP’s Robert N. Baldassano, MD, and Babette S. Zemel, PhD, also contributed to the Journal of Clinical Endocrinology & Metabolism (JCEM) study.

A chronic bowel disease, Crohn’s disease (CD) is marked by inflammation of the gastrointestinal tract that can lead to narrowed and blocked intestines and ulcers. According to the Crohn’s and Colitis Foundation of America, CD affects “as many as 700,000 Americans,” and is seen more often in adolescents aged 15 to 35 years.

In addition to its abdominal symptoms, CD is also associated with an impact on bone health and growth. A review published in the World Journal of Gastroenterology notes “growth failure and impaired nutritional status” are seen in 65 to 85 percent of young CD patients, and 15 to 40 percent of those patients “continue to suffer from growth deficiency through the course of their disease.”

The current JCEM study investigated the effect the drug infliximab had on bone density and structure in a cohort of 74 patients aged 5 to 21 years. The researchers evaluated the patients over a twelve-month period, comparing the cohort’s results to data from 650 healthy reference patients who took part in a larger study of bone health.

Infliximab works by blocking tumor necrosis factor alpha (TNF-α), a cell signaling protein (cytokine) that per the JCEM paper, “has direct adverse effects on bone metabolism and plays a pivotal role in CD pathogenesis.” While previous studies had shown that infliximab treatment had an effect on CD patients’ growth, the drug’s “impact on bone modeling has not been established,” the researchers write. They measured changes trabecular bone density and cortical area over the course of the 12-month infliximab treatment, hypothesizing it would improve both measures.

Dr. Leonard and colleagues found that the patients’ height, body mass index, trabecular bone density, and cortical area all improved, with the data showing “rapid improvements in disease activity.” In addition, the investigators found improvements were greater in younger patients, which suggests that “childhood provides a window of opportunity for recovery of trabecular and endocortical deficits.”

“We believe this study is important because it is the first to show that blocking this inflammatory cytokine can reverse bone loss,” said Dr. Leonard. “Children can regain bone structure, as well as density.”

Though they caution that their study had limitations and that further research is needed, the researchers note “anti-TNF-α therapy during growth and development is associated with rapid improvements in trabecular [bone density] and cortical structure.”

To read more, see the Journal of Clinical Endocrinology & Metabolism. To learn more about inflammatory bowel disease care and research at The Children’s Hospital of Philadelphia, visit the Center for Pediatric Inflammatory Bowel Disease.

Permanent link to this article: http://blog.research.chop.edu/study-seeks-to-treat-crohns-diseases-effects-on-growth-bone-density/

Jun 16 2015

Fear Shouldn’t Drive Policy: CHOP Expert Offers Vaccine Commentary

vaccineNoting “vaccine-preventable diseases remain a significant threat to children’s health,” in a recent editorial The Children’s Hospital of Philadelphia’s Kristen A. Feemster, MD, MPH, MSHP, calls for “ongoing vigilance.” Dr. Feemster’s editorial, which was published recently in JAMA Pediatrics, reviews vaccines’ successes while also pointing out that exemption laws and increasing vaccine hesitancy mean “the success of vaccines can be fragile.”

Dr. Feemster’s article follows the publication of a study — also in JAMA Pediatrics — showing the effect the introduction of a new vaccine had on invasive pneumococcal disease (IPD). A team of researchers led by the New York City Department of Health’s Andrea C. Farnham, MPH, evaluated the effect the 13-valent pneumococcal conjugate vaccine (PCV13) — which was introduced in 2010 and contains 6 more serotypes than the previous pneumococcal vaccine (PCV7) — had on IPD rates in a population of children younger than five years of age.

The researchers showed the vaccine decreased IPD incidence by 69.6 percent, from 21 cases per 100,000 to 6.4 cases per 100,000. Pneumococcal infection can cause a variety of conditions, from the routine (as in ear infections) to serious conditions like meningitis.

No stranger to weighing in on contentious topics, Dr. Feemster recently contributed a The New York Times opinion piece arguing for an end to philosophical and religious exemptions to school entry vaccine requirements. She also wrote about the need to balance religious freedom and responsibility to one’s community, writing that “society has an obligation to stand up on behalf of children who do not yet have their own informed voice.” Dr. Feemster is currently an attending physician in the Division of Infectious Diseases, a PolicyLab faculty member, and the Vaccine Education Center’s director of research.

Dr. Feemster’s JAMA Pediatrics article comes on the heels of a measles resurgence, with 169 people across the country reported to have the disease between January 1 and May 1, 2015, according to the CDC. In a press briefing about the measles outbreaks, the CDC’s Anne Schuchat, MD, noted most of the people who have been reported to have measles had not been vaccinated. “This is not a problem with the measles vaccine not working,” Dr. Schuchat said. “This is a problem of the measles vaccine not being used.”

Dr. Feemster’s editorial echoes this, as she notes “events show us that the success of vaccines can be fragile; the measles cases associated with Disneyland were preceded by 644 cases in 2014. In 2012, there were more than 40,000 cases of pertussis, the largest number since 1960. These events have garnered media attention and provide a dramatic reminder that vaccines remain an important and necessary health tool.”

“Fear has led to hesitancy and is now influencing the push to make it more difficult to refuse vaccination. Fear should not be driving policy,” Dr. Feemster notes in her JAMA Pediatrics editorial. “Instead, a real-time example of the effect of a successful immunization program should move us to continue to advocate for strong vaccine policies that support uptake of all routinely recommended vaccines.”

To read more, see the May issue of JAMA Pediatrics.


Permanent link to this article: http://blog.research.chop.edu/fear-shouldnt-drive-policy-chop-expert-offers-vaccine-commentary/

Jun 11 2015

Supportive Family Connections Decrease Odds of Violence Exposure

violenceYouth in urban environments often are plagued by high levels of exposure to community violence. They have few safe spaces to spend time and face complex economic and social pressures. Exposure to violence is associated with long-term psychological and physiologic changes that impact behavior and health, and often the same youth who have witnessed or experienced violence are at risk for one day perpetuating the cycle of violence.

For the past three decades, homicide has been the No. 1 cause of death among African-American adolescents in the U.S. and is the second most common cause of death among all U.S. adolescents. From 2007 to 2013, 5,051 young Philadelphians ages 14 to 24 were shot or killed.

As an adolescent medicine physician at The Children’s Hospital of Philadelphia, Alison Culyba, MD, MPH, encounters youth every day who have been exposed to violence within their families, peer groups, or neighborhoods. These experiences motivated her to pursue research to better understand the factors that may be protective against interpersonal violence and find ways to help support youth in urban environments. One of the factors that she has explored is the effect of supportive adult familial connections.

“We know that adult connections are deeply protective to kids across a range of behaviors. However, some people may think that in the midst of certain circumstances, such as violence in urban environments, relationships might not make that much of a difference,” said Dr. Culyba, who is a fellow in the Craig-Dalsimer Division of Adolescent Medicine. “Our goal was to better understand the role of supportive family relationships in protecting youth from violence in urban contexts.”

In a study of 283 males ages 10 to 24 in Philadelphia, 98 percent of whom were African-American, Dr. Culyba and colleagues conducted interviews using a structured questionnaire that assessed participants’ previous violence exposure. Thirty-three percent reported high levels of violence involvement, which included violence perpetration or violence victimization. Thirty percent reported high levels of witnessing violence, and 17 percent reported high levels of both violence involvement and witnessing.

Next, the participants answered questions that characterized the nature of their relationships with family members who they felt played an important role in their lives. The study team analyzed those family trees and identified three overarching categories of relationships: supportive, unsupportive, and mixed features of supportive and unsupportive.

The results showed that 68 percent of participants identified at least one supportive relationship with an adult family member. Those youth with at least one supportive adult relationship were less likely to report both violence involvement and witnessing violence. They most commonly identified mothers as supportive adults in their lives (60 percent), but they also listed fathers (27 percent) and a host of other family members including maternal grandmothers, aunts, uncles, and parents’ significant others.

“This is really great news,” Dr. Culyba said. “Although there are many things on a societal level that still need to be addressed in order to affect youth violence, every family and community should understand that they have a direct and profound impact on protecting youth and young adults. These relationships are really critical as people transition to independence.”

In her future research efforts, Dr. Culyba would like to focus on identifying the specific dynamics within those supportive adult relationships that help to safeguard youth. For example, is there a certain parenting style or conflict resolution approach that parents practice that could reduce the odds that youth will be involved with violence?

“If there are things that we can learn from and help teach parents that would be helpful in their ability to protect their children, I think that would be incredibly important,” Dr. Culyba said.

Dr. Culyba, who also is a PhD student in epidemiology at the Perelman School of Medicine at the University of Pennsylvania, presented an abstract about her study at the Pediatric Academic Societies annual meeting held in San Diego. Dr. Culyba is also an adolescent medicine consultant to the Violence Intervention Program, which provides intensive case management services for youth presenting to the CHOP Emergency Department with injuries due to interpersonal violence.

Learn more about the efforts under way at CHOP to interrupt the cycle of youth violence by visiting the Violence Prevention Initiative.

Permanent link to this article: http://blog.research.chop.edu/supportive-family-connections-decrease-odds-of-violence-exposure/

Jun 10 2015

Teen Driver Safety Researchers Use Simulator to Diagnose Driving

SDA_PART.4Many newly licensed teen drivers do not know how to drive, according to a study by researchers at The Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention (CIRP) and the University of Pennsylvania. Their findings are based on data generated by a validated Simulated Driving Assessment (SDA) they developed that can differentiate between skilled and non-skilled teen drivers.

“We’re providing the science behind the answer to why teens — and some adults — don’t drive well,” said Flaura K. Winston, MD, PhD, scientific director of the CIRP and principal investigator for the SDA line of research. “Some haven’t developed the skills they need to navigate complex driving situations and are crashing due to error.”

teen driver

A common mistake of teen drivers is ineffective braking.

The SDA is a package of software products that runs on commercially available driving simulators. It is a safe way to assess novice drivers’ skills in high-risk driving scenarios. As a standard protocol to evaluate teen driver performance, the SDA has the potential to screen and assess for licensure readiness and could be used to guide targeted skill training.

Study participants were exposed to a series of “drives” during a 35-minute session that incorporated 22 variations of the most common ways teen drivers crash. The researchers analyzed numerous aspects of the drivers’ performance, from steering and braking reaction times to eye movement and headway time. Although the novice teen drivers were adept at basic driving skills such as using turn signals, the more advanced skills such as anticipating and responding to hazards proved challenging.

Nearly 43 percent of newly licensed teens (within three months of licensure) had a simulated crash at least once. For licensed, experienced adult drivers, that percentage was 29 percent. For every additional error committed during the SDA, the risk for crashing or running off the road increased by 8 percent.

The study, published in the journal Injury Prevention, followed more than a decade of foundational research regarding young driver crashes and more than five years of research to create and validate the SDA. Previous studies of newly licensed teenage drivers indicate that they exit the learner period with significant skill deficits, leading to a much higher risk of crashing compared with more experienced drivers. For teens in the U.S., motor vehicle crashes remain the number one cause of death.

Catherine McDonald, PhD, RN, lead author of the study and a teen driver safety researcher at the University of Pennsylvania (Penn) School of Nursing and CIRP, sees an important role for the SDA while teens are still in the learner period and for those who are licensed but may have crash risks related to their skills or behaviors.

“What our research tells us is that a validated simulated driving test could be used to assess the driving skills needed to avoid crashes,” Dr. McDonald said. “If we can identify driving skill deficits in a safe, simulated environment, then we can tell families and driving instructors what to focus on during supervised practice drives or how to help those with citations or crashes who are already licensed.”

Parents and driving instructors can find research-based resources to help make their practice drives more effective and to help teens develop crucial skills that prevent crashes by visiting teendriversource.org.

To learn more, please check out part 1, part 2, and part 3 of the Simulated Driving Assessment blog series.

View some of the critical errors that result in the most common serious crashes:

Following Too Closely

Ineffective Braking

Left Turn

Permanent link to this article: http://blog.research.chop.edu/teen-driver-safety-researchers-use-simulator-to-diagnose-driving/

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