American Academy of PediatricsSection on Emergency Medicine

September 12, 2010

Charles G Macias MD, MPHBaylor College of Medicine- Texas Children’s Hospital

Houston, Texas

Network: stakeholders

• A network of volunteer researchers affiliated through membership in the American Academy of Pediatrics– 159 active members– Represent 52 academic institutions– 20 institutions have infrastructures to potentiate

implementation of almost all PEMCRC studies

Active research collaboratives

Study

Collaborative

Number of Investigators

Number of Institutions

Number of

patients

Number of publications

Additional substudies

Meningitis 24 20 3295 4+1 4+1

SBI in infants 11 8 1248 4 5

UTI 30 19 2477 3 abstracts 3 planned

Appendicitis 19 10 ? (2000 in Dec) of 2500

Data collection

closed April

2 planned

MgS04 asthma

survey

10 8 324 1 abstract

1 submission

0

POISE 25 25 527 (interns)

0 Network

H1N1 PERN Study

99 99 ? 1 0

Current considerations

• Virome project: genetic signatures– To be submitted as an R01– Partners:

• Washington University/St Louis Children’s Hospital• Baylor College of Medicine/Texas Children’s Hospital• University of Louisville• Vanderbilt University• University of Missouri• Cornell University• Oregon Health Sciences University• Children’s Hospital of Philadelphia

– Specific aims:• Directed PCR/gene sequencing for febrile 0-6 mo• Study virus-specific host gene expression/biomarkers

Future studies

– Sedation survey for interdisciplinary practices– Non-invasive PPV in asthma

Collaborative: meningitis• Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk

of bacterial meningitis. Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM, Schremmer RD, Schwab SH, Agrawal D, Mansour KM, Bennett JE, Katsogridakis YL, Mohseni MM, Bulloch B, Steele DW, Kaplan RL, Herman MI, Bandyopadhyay S, Dayan P, Truong UT, Wang VJ, Bonsu BK, Chapman JL, Kanegaye JT, Malley R; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. JAMA. 2007 Jan 3;297(1):52-60.

• Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. Nigrovic LE, Malley R, Macias CG, Kanegaye JT, Moro-Sutherland DM, Schremmer RD, Schwab SH, Agrawal D, Mansour KM, Bennett JE, Katsogridakis YL, Mohseni MM, Bulloch B, Steele DW, Kaplan RL, Herman MI, Bandyopadhyay S, Dayan P, Truong UT, Wang VJ, Bonsu BK, Chapman JL, Kuppermann N; American Academy of Pediatrics, Pediatric Emergency Medicine Collaborative Research Committee. Pediatrics. 2008 Oct;122(4):726-30.

• Children with bacterial meningitis presenting to the emergency department during the pneumococcal conjugate vaccine era. Nigrovic LE, Kuppermann N, Malley R; Bacterial Meningitis Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Acad Emerg Med. 2008 Jun;15(6):522-8.

• Diagnostic value of immature neutrophils (bands) in the cerebrospinal fluid of children with cerebrospinal fluid pleocytosis. Kanegaye JT, Nigrovic L, Malley R, Cannavino CR, Schwab SH, Bennett JE, Mohseni MM, Wang VJ, Katsogridakis YL, Herman MI, Kuppermann N. Pediatrics. 2009 June;123(6):e967-71.

Submitted: » Low risk of bacterial meningitis in children with a positive enteroviral

polymerase chain reaction (EV-PCR) test (submitted)

Collaborative: SBI• Risk of serious bacterial infection in young febrile infants with respiratory syncytial vir

us infections. Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, Schor J, Bank D, Fefferman N, Shaw KN, Kuppermann N; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Pediatrics. 2004 Jun;113(6):1728-34.

• Clinical and demographic factors associated with urinary tract infection in young febrile infants. Zorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, Schor J, Bank D, Shaw KN, Kuppermann N; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Pediatrics. 2005 Sep;116(3):644-8.

• Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. Shah SS, Zorc JJ, Levine DA, Platt SL, Kuppermann N. J Pediatr. 2008 Aug;153(2):290-2.

• Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Krief WI, Levine DA, Platt SL, Macias CG, Dayan PS, Zorc JJ, Feffermann N, Kuppermann N; Pediatrics. 2009 Jul;124(1):30-9.

– Pending: » Radiographic findings and pneumonia study» Decision rule for management

Collaborative: UTI• Clinical course of febrile infants 29-60 days of age with

urinary tract infections in a large multicenter research network.

• Abstracts and manuscripts– Manuscript: Clinical course of febrile infants 29-60 days of age

with urinary tract infections in a large multicenter research network. Submitted to Pediatrics

– 3 abstract presentations• Risk factors and decision models for UTI and bacteremia. • CSF pleocytosis with UTI (manuscript drafted)

– Patterns of resistance: analysis underway

Collaborative: appendicitis• Clinical decision rules for pediatric appendicitis• Progress: 10 sites with >2,000 patients enrolled• Substudies:

– CRP in appendicitis– Economic analysis of CT vs US

Collaborative: NA practice patterns of IV magnesium in asthma

• Partnership with PERC: Schuh S: PI• Electronic survey of US and Canadians PEM physicians

– 66% response rate (213/324)– IV Magnesium rarely used to prevent hospitalization (7%) vs

71% to prevent PICU– Submitted for review– Support for prospective study within PERC

Collaborative: POISE

• POISE network: simulation study– Permanent partnership with network support– Study 1:

• 23 sites, 25 investigators, 521 intern/subjects• Aims:

» Demonstrate improvement in LP success rates» Link skills performance on simulator to real patient

performance» Describe qualitative barriers to simulation training

Collaborative: H1N1

Pediatric Emergency Research Network

-H1N1 Case control study

99 centers worldwide

Network: support

• Limited administrative support– Monthly teleconferences for each study collaborative-AAP– AAP supports venues for biannual meetings but individuals

participate with their own resources– No permanent infrastructure for patient enrollment or chart

review: no research coordinator support– Research collaboratives bring their own funding where

necessary• Data center

– Data processing and data quality support centralized– Contributed personnel support (informatician, biostatistician)– Projects

» UTI collaborative

» Appendicitis collaborative

» POISE network

» H1N1 PERN study

Challenges

• Permanent infrastructures and infrastructure funding– Iterative process of self-definition based upon:

• Skills sets of members

• Industry

• Growth of PECARN and maturing of federal recognition for PEM research

• Availability of funding

• Strength of the AAP: people and money

• Young investigators, mentorship for longevity of the network

Administrative achievements

• Productivity based upon volunteerism with only loose infrastructure support– Strength of the drive of PEM researchers

– Evolution of efficiencies and expertise in research• Development of an increased number of mentors for support

» PECARN researchers/mentors

» EMSC/NEDARC partnership- young investigator grant writing scholarship

• Evolving partnership with pharmaceuticals for investigator initiated grants

• Formalization of a survey review mechanism separate from study review process: needs assessments for each collaborative

The future

• Virtual collaboratives enhancements– www.pemcrc.org– Migrating the AAP SOEM network to www.pemnetwork.com– Enhancement of the network will allow subsites for

www.pemcrc.org to create• Wikified sites for active protocol development for each collaborative

• Multi-media for virtual training

• Shared compliance document libraries

• Web/pod casts

Network leadership

• Leadership: – Chairman and Associate Chairman with 6 year positions (3 year

overlap)– Change in leadership in October: David Schnadower chair

• Consider a robust overlap of leadership given the length of projects