American Academy of Pediatrics Section on Emergency Medicine September 12, 2010

1. American Academy of Pediatrics Section on Emergency Medicine September 12, 2010 Charles G Macias MD, MPH Baylor College of Medicine- Texas Children’s Hospital Houston, Texas

2. 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

4. Active research collaboratives

5. 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

6. Future studies • Sedation survey for interdisciplinary practices • Non-invasive PPV in asthma

7. 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)

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

9. 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

10. 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

11. 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

12. 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

13. Collaborative: H1N1 Pediatric Emergency Research Network -H1N1 Case control study 99 centers worldwide

14. 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

15. 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

16. 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

17. 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

18. 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