Jan 23 2015

Beyond the Bandages, Nurses Treat Trauma


Pediatric nurses play a key role in preventing injury-related post-traumatic stress by providing trauma-informed care.

It’s no surprise that nurses know trauma. With roughly 2.7 million nurses working in the U.S., versus about 900,000 physicians (according to the American Association of Colleges of Nursing and The Henry J. Kaiser Family Foundation, respectively), nurses are on the front line of clinical care. Nurses are very often the first clinical staff patients meet, and do everything from performing triage and physical exams to conducting research.

Indeed, a recent study from CHOP and Penn State Hershey Children’s Hospital published in the Journal of Pediatric Nursing confirms that pediatric trauma nurses are knowledgeable about practicing trauma-informed care, but points to the need for additional nurse training to help families cope after a child’s injury.

When an injury occurs, both the child and family members may experience traumatic stress reactions interfering with a full recovery. Pediatric nurses play a key role in preventing injury-related post-traumatic stress by providing trauma-informed care, which includes recognizing pre-existing trauma, addressing stress associated with the traumatic event, minimizing potentially traumatic aspects of treatment, and identifying children who need additional monitoring or referrals for more help.

Researchers surveyed nurses across five trauma centers about their knowledge, opinions, and current practices in addressing psychological recovery in their injured patients. More than 90 percent of the nurses surveyed recognize the importance of attending to psychosocial needs as part of trauma nursing care, and 75 to 80 percent report that they encourage parents to turn to family and friends for support and help parents manage a child’s pain and anxiety during procedures. However, fewer nurses surveyed reported directly assessing a child or parent’s distress or providing specific instruction in how to cope with difficult or painful experiences.

“When a child is hospitalized for an injury, nurses play a key role not only in medical care, but also in helping families cope and fully recover emotionally,” said Nancy Kassam-Adams, PhD, director of CHOP’s Center for Pediatric Traumatic Stress. “Taken together with other recent studies that found only one in five trauma centers routinely screen child and youth for traumatic stress responses, these results help to identify gaps in current practice and point to possible policy and training needs.”

The results of this survey suggest that efforts to improve trauma-informed pediatric nursing care should highlight specific skills related to helping patients and their parents manage emotional responses to difficult medical experiences.

In a blog post about the study published on the Center for Research and Injury’s blog, CHOP nurse Christie Alminde, RN, CPN notes nurses’ skills and experiences are “well suited to provide excellent trauma-informed care.”

“When we incorporate an understanding of traumatic stress into our routine interactions with children and families, we can provide trauma-informed nursing care that not only reduces the impact of difficult or frightening medical events for our pediatric patients, but also helps with their emotional reactions to illness and injury,” writes Alminde.

For more information and resources about medical traumatic stress, see the Center for Pediatric Trauma Stress. And to learn more about this study, see the full press release.

Permanent link to this article: http://www.research.chop.edu/blog/beyond-bandages-nurses-treat-trauma/

Jan 21 2015

$50 Million Gift to Fund Research Transformation at CHOP

Raymond G. Perelman.

CHOP will establish the Raymond G. Perelman Campus, an eight-acre area that will serve as a hub of pediatric research and clinical innovation at CHOP.

The Children’s Hospital of Philadelphia (CHOP) today announced a $50 million gift from Raymond G. Perelman. This gift, equal to the largest ever received by CHOP, will directly support a wide range of pediatric research, tackling the toughest and most challenging pediatric illnesses and establishing CHOP as a global center for innovative pediatric study.

In recognition of this extraordinary gift for research, CHOP will establish the Raymond G. Perelman Campus, an eight-acre area that will serve as a hub of pediatric research and clinical innovation at CHOP.

“The significant research funding associated with this gift underscores the commitment of Raymond Perelman to world-class pediatric research and medicine,” said Mortimer J. Buckley, chair, Board of Trustees at The Children’s Hospital of Philadelphia. “Through his generosity, Mr. Perelman is first and foremost improving the lives of children for generations to come and we will always be grateful for his altruism,” he said.

Raymond G. PerelmanBorn in Philadelphia, Raymond G. Perelman was raised in the Feltonville and Olney sections of the city and attended the University of Pennsylvania. After serving in WWII, he began a 50-year career with American Paper Products Co., and is currently CEO of RGP Holdings. Mr. Perelman has served on many Boards of Directors, and has been active in numerous civic organizations, including the Philadelphia Museum of Art, Penn Medicine, and the Albert Einstein Health Center.

“We know first-hand the tremendous resource that CHOP represents to families in the Philadelphia region, across the country and around the world,” said Raymond G. Perelman. “This gift will help to ensure that critically important pediatric research, conducted on this campus, remains second to none; in addition to making a tangible difference in the lives of children around the globe for many years to come, it is my hope and expectation that advances in medical research funded by this gift will benefit us all,” he said.

The gift also establishes the “Raymond G. Perelman Research Fund,” that will provide direct support for:

  • Raymond G. Perelman Center for Cellular & Molecular Therapeutics, designed to re-engineer the body’s immune system to fight, and defeat, cancer, metabolic diseases and other catastrophic illnesses through the efforts of the world’s leading experts in immunotherapy and molecular therapy.
  • Perelman Scholars, two new tenure-track faculty positions at CHOP to be filled by candidates from among the world’s finest pediatric researchers.
  • Perelman Fund for Research Innovation, a permanent source of reliable funding for the CHOP Research Institute to strategically identify and support new pilot research initiatives.
  • Perelman Endowed Chair in Pediatric Ophthalmology to support a highly skilled researcher and physician-scientist seeking to break new ground and forge novel paths critical to understanding and treating ophthalmologic diseases in children.
  • Research Support for general research activities of the CHOP Research Institute.

The newly named Raymond G. Perelman Campus comprises an eight-acre portion of the CHOP site located on Civic Center Boulevard just south of the main hospital and encompasses its most state-of-the-art research and clinical centers, including the Ruth and Tristram Colket, Jr. Translational Research Building, which opened in 2009; the new Buerger Center for Advanced Pediatric Care, under construction and slated to open this summer; and a 2.6-acre landscaped plaza.

To learn more about this extraordinary gift, see the full press release.

Permanent link to this article: http://www.research.chop.edu/blog/50-million-gift-fund-research-transformation-chop/

Jan 20 2015

Office Visits May Be Too Short to Detect Autism Risk

autismIdentifying autism spectrum disorder (ASD) risk early is imperative, because the earlier autism is detected the earlier clinicians will be able to intervene. In general, the younger the patient, the more effective ASD interventions are. However, according to a new study published in Pediatrics, short observations — such as an office visit — may be insufficient when it comes to assessing autism risk.

Led by the Center for Autism Research’s Judith S. Miller PhD, MS, the researchers studied a group of children aged 15 to 33 months with autism, speech delays, and typical development. The researchers asked licensed psychologists with autism expertise — who were unaware of the study participants’ status — to analyze two 10-minute video samples of the participants’ autism evaluations. The experts measured five behaviors, including responding, initiating, vocalizing, play, and response to name.

The article’s first author was Terisa Gabrielsen, PhD, NCSP, of Brigham Young University (BYU). Before moving to BYU, Dr. Gabrielsen completed training at CHOP, where she and Dr. Miller conducted research that informed the current study. That work, also published in Pediatrics, examined the feasibility of a formal autism screening process.

In the current study, the researchers found the experts missed referrals for 39 percent of the children in the autism group. Detecting autism risk based on the brief observations alone was challenging because the children who had autism showed more typical behavior (89 percent of the time) than atypical behavior (11 percent) during that short window.

“It’s not often the pediatrician’s fault that referrals are missed,” Dr. Gabrielsen said. “Even autism experts missed a high percentage of referrals within that short timeframe. Decisions for referral need to be based on more information, including autism screening and information from parents.”

In March of 2014, the Centers for Disease Control and Prevention announced that one in 68 children in the U.S. has an ASD — a 29 percent increase over the 2012 rate. The seemingly growing prevalence of ASD demonstrates the need for accurate autism referral decisions. This decision-making process should include parent observations, developmental testing, a detailed history, and autism screening tools in addition to clinical judgment, the research team concluded.

“Certainly, some young children with autism are clearly impaired and easy to recognize,” noted Dr. Miller in a press release put out by BYU. “However, this study looked at the entire range of children who present to the pediatrician’s office, and we found that many children’s impairments are not immediately obvious. For these children, formalized screening instruments and more time with a specialist may be critical.”

For more information about autism and autism research, see the Center for Autism Research. A description of diagnostic tests and other information on how parents can spot the developmental delays associated with ASD is available in the diagnosis section of Autism Roadmap. The Roadmap provides directories of service providers, community resources, government programs, ideas for various stages of childhood and beyond, and explanations of the latest research on ASD treatments and interventions.

Permanent link to this article: http://www.research.chop.edu/blog/office-visits-may-short-detect-autism-risk/

Jan 16 2015

Translational Research Project Explores Enzymes’ Cancer Role

enzymeWith support from the National Cancer Institute, The Children’s Hospital of Philadelphia Matthew D. Weitzman, PhD, is studying the relation of a family of proteins to cancer. The proteins in question, the ponderously named APOBEC3 (apolipoprotein B mRNA-editing enzyme, catalytic polypeptide-like 3) family of deaminases, play a key role in defending against viruses, but are also being investigated as a possible cause of cellular DNA damage that can lead to cancer.

Dr. Weitzman has been working closely with Abby Green, MD, currently an instructor in Pediatric Oncology. In July of 2014 Dr. Green received a grant of her own to study APOBECs — a two-year Young Investigator Award from Alex’s Lemonade Stand Foundation (ALSF).

Drs. Weitzman and Green’s work seeks to understand better how these enzymes disrupt the genome and cause mutations, and how APOBECs (pronounced AE-POE-BECK) are regulated. Their broad goal is to discover and develop new treatment methods based on a deeper understanding of the relationship between these enzymes and cancer cells. For her part, Dr. Green’s ALSF grant funds an investigation into whether the DNA mutations caused by APOBECs make cancer cells more receptive to drugs.

The work builds on recent investigations into the enzymes’ relation to cancer by Dr. Weitzman and others. In 2011 he published a paper in EMBO Reports with colleagues from the Salk Institute showing that some APOBECs could cause genomic instability. His five-year R01 grant from the National Cancer Institute seeks to build on the EMBO Reports work.

“The grant is asking basically can we show that these enzymes actually cause those [mutational] signatures and fulfill what is predicted retrospectively,” Dr. Weitzman said. “The next questions address what regulates activity, what makes sure it doesn’t happen normally, what are the modifications, what are the interactive proteins, where’s it expressed and localized in the cell, and other fundamental questions about these potentially harmful enzymes.”

Potentially Paradoxical Proteins

 Though APOBECs have been the focus of increased attention in recent years, they remain poorly understood. How, some have wondered, could enzymes that perform an immune function also induce cancer-causing mutations? A review of these enzymes offered a possible answer: age. In their Intrinsic Immunity, Current Topics in Microbiology, the University of Minnesota’s Reuben S. Harris, PhD, and Eric W. Refsland, PhD, address the question of how, and why, enzymes whose primary role is to fight viruses could be a cause of human cancer.

“An attractive explanation for this apparent conundrum may be that [APOBECs’] innate function is important early in life and for the health of the species, for instance, in germ cells or early development, whereas the toll of cancer is not imposed in most instances until after the reproductive years,” they note. “In any event, much more work is now justified on APOBEC3B and its role in breast and, potentially, other human cancers.”

Hence the importance of studies like Drs. Weitzman and Green’s. Dr. Weitzman pointed out that while cancer genome sequencing studies have revealed a great deal of information about how cancer arises, and discovered genes associated with certain cancers, they don’t necessarily provide the mechanism by which things happen.

“We want to bridge that gap,” said Dr. Green.

And though their study is mechanistic, greater knowledge of APOBECs’ role in causing cancer, and how this family of enzymes is regulated, could lead to diagnostic and therapeutic approaches in the future. “If we find that these APOBECs are involved in pediatric cancers, there may be a diagnostic role, or a therapeutic opportunity. We have lots of translational ideas, but we just have to get this first work done,” Dr. Green added.

Indeed, it is CHOP’s unique ability to pair laboratory researchers with clinicians like Dr. Green that allows investigators to think more translationally, Dr. Weitzman noted. He said that his work has really benefitted from the input and expertise of Dr. Green, who is the first clinician to work in his lab.

“CHOP has this ability to pair basic researchers with clinicians, and both sides stimulate each other to think together about translational ideas,” Dr. Weitzman said.

Permanent link to this article: http://www.research.chop.edu/blog/translational-research-project-explores-enzymes-cancer-role/

Jan 14 2015

Researchers Receive Grant to Study TMJ Biology, Long-term Maintenance

TMJOf all the joints in the body, perhaps the most unique, complex, and understudied is the temporomandibular joint (TMJ). The TMJ, which is located close to the ears, is a bilateral movable articulation, connecting the lower jaw (mandible) to the bone at the side of the skull (temporal bone). Its structure include a distinctive feature called an articular disc that acts as a shock absorber and reduces friction so that the bony parts of the joint can glide smoothly, allowing us to chew, talk, yawn, and open our mouths wide to say “Ahhh.”

Researchers at The Children’s Hospital of Philadelphia, Eiki Koyama, DDS, PhD, a faculty member in the Division of Orthopedics, and Hyun-Duck Nah, DMD, PhD, an orthodontist in the Division of Plastic and Reconstructive Surgery who works with patients who have craniofacial deformities, recently received a grant from the National Institute of Dental & Craniofacial Research to study the development of the TMJ, the mechanisms that maintain it, and how these processes may be altered in disease. They aim to use this knowledge to inform future therapeutic strategies in pediatric and adult medicine.

The TMJ begins to form within the first few months after conception, experiences active growth during childhood and adolescence, and then undergoes adaptive remodeling throughout life. The exact prevalence of TMJ disorders in the general pediatric population is uncertain, but guidelines from the American Academy of Pediatric Dentistry cite that upwards of 25 percent of children ages 5 to 17 have some symptoms of TMJ disease, and 1 percent to 2 percent are in need of treatment.

Pediatric TMJ disorders can be congenital or acquired, such as craniofacial abnormalities, juvenile rheumatoid arthritis, and injuries or infection that damage the joint. Symptoms and signs of TMJ disorders vary depending on etiology and severity, but commonly include difficulty opening the mouth, locking of the joint, difficulty with mastication and nutrition, and facial and jaw muscle pain. Furthermore, defective TMJ function often results in under-development of the mandible and abnormal facial growth.

In previous research, Dr. Koyama’s group demonstrated that mice with deletion of a specific gene, Indian hedgehog (Ihh), failed to form a normal TMJ. The joint lacked integral components including its distinctive articular disc, joint cavities, and the specialized cell layers that produce lubricin. Lubricin is a lubricant that protects the TMJ from frictional loads and thus is essential for long-term maintenance of joint integrity.

In the current study, the Koyama and Nah team now plan to further define the roles of Ihh and additionally to delineate the role of two genetic pathways, TGF-β1 and PTHrP, that they suggest Ihh uses to orchestrate TMJ formation, function, and lubricin production. They predict that deterioration of joint lubrication with age or by other insults may underlie disc adhesion and degenerative TMJ disorders, which are prevalent in the adult population.

While this research is still at the basic science stage, Dr. Nah, who is also a research associate professor of surgery at the Perelman School of Medicine at the University of Pennsylvania, said that the ultimate goals of the study include translation of findings to recreate a functional TMJ for those patients with missing or defective TMJs.

Permanent link to this article: http://www.research.chop.edu/blog/researchers-receive-grant-study-tmj-biology-long-term-maintenance/

Jan 12 2015

Researchers Lay Groundwork for Novel Therapy for Huntington’s Disease

Huntington’s Disease

The mutant HTT protein (mHTT) damages a brain region called the striatum, resulting in involuntary movements and severe cognitive and emotional disturbances.

New findings by researchers in the Center for Cellular and Molecular Therapeutics (CCMT) at The Children’s Hospital of Philadelphia suggest that an intricate pathway crucial to the development of Huntington’s disease (HD) rests on a “biological teeter-totter” that when carefully balanced could help to control this devastating neurodegenerative disorder.

HD affects about 30,000 Americans and is an incurable, inherited disease entailing progressive loss of brain cells and motor function, usually beginning in midlife. A defective gene produces repeated copies of a protein called huntingtin, or HTT. The mutant HTT protein (mHTT) damages a brain region called the striatum, resulting in involuntary movements and severe cognitive and emotional disturbances. A key signaling protein called mTORC1 that regulates cell growth and metabolism plays a major role in HD.

In their experiments, study leader Beverly L. Davidson, PhD, director of the CCMT, and co-investigators adjusted levels of mTORC1 in mice bred to model features of HD. They injected bioengineered viruses as a gene therapy tool to carry DNA that directed the production of regulatory proteins called Rheb and Rhes that act along the mTORC1 pathway. After the researchers restored mTORC1 activity to more normal levels, brain areas that had begun to atrophy recovered volume and permitted better motor function.

“It was particularly exciting to see plasticity in the neurons impaired by mHTT,” said Dr. Davidson, who also is on the faculty of the Perelman School of Medicine at the University of Pennsylvania. “This shows that brain cells are capable of responding even after disease onset and hints at the potential for reversing Huntington’s disease.”

She added that restoring proper balance to these delicate biological processes may offer even broader benefits in treating other neurological diseases, such as amyotrophic lateral sclerosis (ALS), fragile X mental retardation, and autism. Fragile X mental retardation and autism both feature overactive mTORC1 activity, while mTORC1 is reduced in ALS and HD.

“This pathway is poised on a biological teeter-totter, and our work highlights that it’s essential to control its activity to find the appropriate balance for each disease,” Dr. Davidson said.

In the future, the research team will focus on increasing their understanding of how they can carefully manipulate the dysregulated pathway to treat HD, with the goal of finding a potential drug therapy. Much work remains, as researchers must identify drug candidates that appropriately activate the mTORC1 pathway. Although gene therapy vectors were used for this research, Dr. Davidson envisions developing a small molecule that can appropriately modulate this pathway. Such a treatment might be combined with a gene therapy approach, also being pursued by her team and other groups, delivered directly to the brain to curtail mHTT expression.

The study team published its results online Dec. 31 in the journal Neuron. They performed a substantial part of this research in Dr. Davidson’s laboratory at the University of Iowa, before she and many of her colleagues moved to CHOP in 2014. John H. Lee, the paper’s first author, remains at the University of Iowa, where he is completing his MD/PhD training. For more information about their research, a press release is available.

The National Institutes of Health and the Roy J. Carver Trust supported this study.

Permanent link to this article: http://www.research.chop.edu/blog/researchers-lay-groundwork-novel-therapy-huntingtons-disease/

Jan 09 2015

Research Improves Training, Assessment of Teen Driving Skills

teen drivingA recent article in the Wall Street Journal on “one of the most dreaded rites of child-rearing — teaching a teenager to drive” — notes recent research on teen driving and training can help teens learn to be better drivers and so avoid accidents. The article touches on studies by Center for Injury Research and Prevention (CIRP) staff: one that examined a web-based intervention, and a more recent investigation of teen driving error frequency.

Though many parents do a good job of teaching the basics of driving — “steering, parking, and controlling the car” — the Wall Street Journal article notes that parents “are not so good, however, at teaching the skills young drivers need to actually avoid accidents, according to new research. Now, there are new techniques and even guides that have grown out of new scientific research into the parent-child dynamic in the car.”

Two studies cited by the Wall Street Journal article were led by CIRP experts. In August, JAMA Pediatrics published a study authored by Jessica Mirman, PhD, that examined the effectiveness of the web-based Teen Driving Plan (TDP) tool in improving teen driving performance as measured by the Teen On-road Driving Assessment (tODA).

Along with the Center for Injury Research and Prevention’s Allison E. Curry, PhD, MPH, and Flaura K. Winston, MD, PhD, among others, Dr. Mirman measured the TDP’s effectiveness in increasing the quantity of practice and teens’ driving performance in 217 teen-parent dyads. The dyads were randomized to receive either the TDP or standard Pennsylvania driver manuals.

She found that the “dyads reported more practice in 5 of the 6 environments and at night and in bad weather compared with control dyads.” In addition, fewer teenagers who used the TDP had their tODA’s terminated for safety reasons than did the control group, who received PA manuals. The study’s “evidence suggest that the TDP improves supervised practice and the driving performance of prelicensed teenaged drivers,” the study author’s notes.

Indeed, as the Wall Street Journal article notes, one parent who participated in Dr. Mirman’s study says the TDP helped improved her driving lessons. “Having a game plan to work with, and to be accountable for, was better,” said Monica Pica.

The second study, led by Dennis Durbin, MD, MSCE, director of CHOP Research’s Office of Clinical and Translational Research, follows Dr. Mirman’s work by investigating driving errors made by teens during their learner’s permit period. This study, published in Accident Analysis & Prevention, used the tODA at 12 and 24 weeks of study to examine driving errors in teen and adult drivers.

Dr. Durbin and colleagues found that 55 percent of novice teen drivers committed “critical errors” at the 12-week tODA and 54 percent committed errors on the 24-week tODA. Only one experienced adult driver committed a critical error at 12 weeks and one at 24 weeks.

“In comparison to a group of experienced adult drivers, a substantially higher proportion of learner teens committed safety-relevant critical driving errors at both time points of assessment,” the authors note. The finding, they write, “suggest further research is needed to better understand how teens might effectively learn skills necessary for safe independent driving while they are still under supervised conditions.”

To read more, see the Wall Street Journal article, “Better Ways to Teach Teens to Drive.” And to learn more about the research being conducted at the Center for Injury Research and Prevention, see the CIRP website.

Permanent link to this article: http://www.research.chop.edu/blog/research-improves-training-assessment-teen-driving-skills/

Jan 07 2015

CHOP Expert Elected to Scoliosis Research Society Presidency

Scoliosis Research SocietyThe Children’s Hospital of Philadelphia’s John P. Dormans, MD, FACS, was recently elected to the presidency of the Scoliosis Research Society’s board of directors. The former chief of Children’s Hospital’s Division of Orthopedics and a professor of Orthopedic Surgery at the Perelman School of Medicine, Dr. Dormans is an internationally recognized orthopedic surgeon and spine disorder researcher.

A condition in which the spine is curved sideways, scoliosis is most often seen in late childhood and adolescence, and is more common in girls than boys. There are several different types of scoliosis, including congenital, neuromuscular (when it is associated with cerebral palsy or another condition), and idiopathic scoliosis, or that of largely unknown origin. Idiopathic scoliosis affects approximately 2 to 3 percent of the U.S. population, about 9 million Americans.

The Scoliosis Research Society is a premier organization of roughly 1200 leading spine surgeons and researchers from more than 50 countries. Since it was founded in 1966, according to the Society’s website the Scoliosis Research Society “has maintained a commitment to research and education in the field of spinal deformities.” Dr. Dormans’ fellow board members hail from the University of Minnesota, Johns Hopkins, and Louisville, Ky.’s Norton Leatherman Spine Center.

Scoliosis Research SocietyIn late 2014, Dr. Dormans published a series of papers on scoliosis and orthopedics, including one in the Journal of Children’s Orthopaedics on surgical management of fibrous dysplasia (a condition in which fibro-osseous tissue proliferates in bone) of the proximal femur, and a Journal of Pediatric Orthopaedics (JPO) study of scoliosis in children who have Aicardi syndrome. A rare disorder occurring mainly in females, Aicardi syndrome is characterized by brain and eye abnormalities, distinctive facial features, and recurrent seizures that can be difficult to treat.

In the JPO paper, Dr. Dormans — along with CHOP’s Emmouil Grigoriou, MD, who held a 2013-2014 Orthopedic Surgery Research Fellowship — described for the first time scoliosis in patients with Aicardi syndrome. By performing a review of records of Aicardi syndrome patients treated for scoliosis at Children’s Hospital, they found scoliosis represents “a clinically significant problem that is underdiagnosed and overshadowed by the other severe medical complications associated with the syndrome.”

“It certainly is an honor to serve as President of the Scoliosis Research Society,” Dr. Dormans said. “I look forward to working with my fellow members to advance scoliosis research and care.”

To learn more about scoliosis and other spine treatments at CHOP, see The Children’s Hospital of Philadelphia’s Spine Program.

Permanent link to this article: http://www.research.chop.edu/blog/chop-expert-elected-scoliosis-research-society-presidency/

Jan 05 2015

Researchers Study Factors That May Complicate Concussion Recovery


A subset of patients may experience a more complicated recovery that can last for months.

Recognition and diagnosis of concussions have exploded over the past decade, mainly due to increased media attention on how professional sports teams deal with these serious injuries. Nearly 173,000 children and adolescents are seen in emergency departments annually for sports- and recreation-related traumatic brain injuries (TBI), including concussions, according to the Centers for Disease Control and Prevention.

“Concussions have become a hot button issue across the country,” said Daniel J. Corwin, MD, of the Division of Emergency Medicine at CHOP. “We have become much more aware and adept at concussion diagnosis and management.”

As the number of children treated for concussions continues to increase, the evidence-based program Minds Matter developed by concussion experts at The Children’s Hospital of Philadelphia has expanded to clinicians in the emergency room and primary care practices. A concussion is a mild TBI caused by a blow or jolt to the head or body that causes the brain to shake. The injury disrupts how well the brain’s cells function and work together, and it can cause multiple symptoms, including headaches and dizziness, sleep problems, confusion, and irritability. Some symptoms are obvious and immediate, while others are more subtle and may not show up for several days.

A subset of patients may experience a more complicated recovery that can last for months. In a retrospective study published in the December issue of the Journal of Pediatrics, Dr. Corwin and colleagues investigated a broad group of characteristics that may help clinicians to identify which patients are most at risk for prolonged recovery.

“We suspect that there is something about these children that may predispose them to having poorer outcomes from concussion and longer recovery times,” Dr. Corwin said. “It is possible that even if a child has mild symptoms, they may have a longer recovery time if they have one of the pre-existing conditions or the specific types of clinical presentations that we studied.”

The study team hypothesized that patients with pre-existing mood disturbances or learning disabilities, dizziness as an initial symptom, abnormal findings upon vestibular examination, a history of prior concussion, and younger age would be associated with a more complicated recovery from concussions. They analyzed data collected via an electronic medical record query from patients aged 5 to 18 with concussion who were referred to CHOP’s sports medicine clinic.

The investigators examined several recovery outcomes, including how long on average it took for patients to be symptom-free (64 days), how long until they were fully cleared to return to learning without any academic accommodations (35 days), and how long until they were fully cleared for all activities, including sports (76 days). Overall, the study reported recovery times that were longer than the healing times estimated in previous studies among the general pediatric population (14 to 28 days).

Because it was a retrospective study, many of the differences that the researchers identified in association with specific patient characteristics did not reach statistical significance, but their findings could spark more in-depth studies of these predisposing factors. For example, the investigators found that patients with a history of anxiety and depression had prolonged recovery time and worse school outcomes.

“They may have underlying abnormalities that make their brain a little more sensitive to a given impact,” Dr. Corwin suggested as a hypothesis for future exploration.

He also anticipates that the study’s findings will prompt more research into how assessment of vestibular deficits could be incorporated into concussion exams to help with prognosis, which already is the standard for care for CHOP’s sports medicine specialists but is not done universally. The vestibular system includes parts of the inner ear and brain that help control balance and eye movements.

One element of the assessment tests near-point convergence, which determines how difficult it is for patients to see an object clearly as it moves closer. In the current study, patients who demonstrated abnormal near-point convergence ended up having prolonged symptoms and poorer school outcomes.

“Usually, an object becomes blurry at about 6 cm,” Dr. Corwin said. “We found that for some patients, an object was blurry at 10 cm to 20 cm, which can make schoolwork quite difficult.”

The study team also considered concussion patients who had difficulty looking horizontally and vertically back and forth rapidly, as they do in a classroom when taking notes. Patients with initial oculomotor abnormalities on physical examination also had prolonged symptoms and poorer school performance.

“Perhaps if these vestibular deficits are present at the initial exam, they could be markers that a concussion injury may cause more severe dysfunction,” Dr. Corwin said, adding that this is an area where researchers could help to provide future data.

Other factors that the study team associated with patients who took longer for their symptoms to resolve included those who reported dizziness or loss of consciousness at the time of injury, at least two prior concussions, and younger age, especially those 12 and under.

Future research also is needed to see how clinicians’ recommendations for physical rest and early cognitive rest — which restricts patients’ exposure to activities that may stress the brain and worsen symptoms, such as sports, schoolwork, computers, texting, or video games — could affect patient outcomes in these high risk groups.

“It can often be challenging to have patients cognitively rest,” Dr. Corwin said. “As clinicians are counseling families and following up with these patients, they can be aware of which children are at increased risk for prolonged recovery and worse outcomes, and hopefully better prepare them and set expectations from the beginning that will encourage them to rest more effectively.”

Permanent link to this article: http://www.research.chop.edu/blog/researchers-study-factors-may-complicate-concussion-recovery/

Dec 30 2014

A Year of Distinction

distinctionWe are fortunate to celebrate another year of firsts at The Children’s Hospital of Philadelphia. In 2014, the Hospital was again tied for the top spot in U.S. News & World Report’s Honor Roll of the nation’s best children’s hospitals. In addition, the publication also ranked the Perelman School of Medicine’s Department of Pediatrics—CHOP’s academic partner—No. 1 in the nation for the second year in a row, marking the 11th consecutive year that the program has been ranked first or second.

Likewise, the researchers, graduate students, technicians, coordinators, and staff that comprise The Children’s Hospital of Philadelphia Research Institute were responsible for a number of firsts and breakthroughs: a groundbreaking extracorporeal life support system for preterm infants; a new method of treating neuroblastoma with nanocarriers; and the first multicenter trial of sleep apnea in children, to name a few.

All of these stories, and many more, are detailed in this year’s CHOP Research Annual Report. Weighing in at 43 articles spread among eight sections, this year’s report focuses on the theme of “distinction” and the stories contained within echo that theme and span the research spectrum, covering everything from genetics to community programs.

In the 2014 Annual Report, you’ll find articles on preventive antibiotics; the creation of the new Penn Medicine/CHOP Friedreich’s Ataxia Center of Excellence, which will seek to advance treatments for the rare neurodegenerative condition; work to raise awareness of palliative care; and several articles on technologies that may change the face of healthcare.

The report also includes the vital statistics that show, briefly, how actively engaged Research Institute investigators are every day: lists of patents; operating expenses, grants, and publications; and a sampling of who’s who in the sprawling, thriving institution that is The Children’s Hospital of Philadelphia Research Institute.

I encourage you to peruse the 2014 CHOP Research Annual Report and continuing letting us know your stories so we can share them. This report is a testament to the diligence of everyone who is part of the growing Research Institute, whose work every day helps to ultimately improve the health of children. And that is our greatest distinction.

Philip R. Johnson, MD
Director, The Children’s Hospital of Philadelphia Research Institute
Chief Scientific Officer and Executive Vice President

Permanent link to this article: http://www.research.chop.edu/blog/year-distinction/

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