Image-guided therapy challenge: Unique pediatric issues and the need for collaboration

Institute bioengineer and technical director Kevin Cleary, PhD, often talks about the lack of pediatric focus in image guided therapy development. The unique needs and challenges of treating children require completely unique approaches, not merely adaptation of technology from adult applications.

The recent National Center for Image-Guided Therapy Workshop included a visit to Children’s National Medical Center, and focused on issues in developing these technologies for children. Attendees toured the operating rooms, as well as the working laboratories of the Sheikh Zayed Institute.

Children’s National specialists discussed the need to develop treatments specifically for children—as an important, under-served area. Pediatric cardiologist Joshua Kanter, MD, pediatric urologist Amy Burns, MD, pediatric otolaryngologist Brian Reilly, MD, pediatric orthopaedist Matthew Oetgen, MD, and pediatric interventional radiologist Karun Sharma, MD, PhD, discussed the promise and need for further pediatric-focused development, as well as some of the challenges unique to caring for children.

1. Smaller spaces for surgeons to maneuver in. Although laparoscopic tools, including those in current surgical robotics and interventional cardiology, appear small, they are designed for adults. Even smaller tools must be created to efficiently apply to children.
2. The ongoing growth of the patient. Unlike adults, children are still growing, and their anatomy changes as they grow. This is of great concern, for instance, in interventional catheterization procedures—what happens if a child’s artery outgrows a stent? 
3. Different movement. Pediatric procedures must consider that children climb, play, jump, and run. Any devices or interventions must be able to withstand the active pace of a child.  

Some career innovators in image-guided therapies are taking up this challenge because the need and the promise are so great. Through partnerships with pediatric-focused institutions, engineers and physicians work directly with surgeons, radiologists, cardiologists, and others to identify needs and explore new solutions.

One example is Gernot Kronrief, PhD, of the Austrian Center for Medical Innovation and Technology, who is investigating whether a novel robotic technology he developed—referred to in his lab as the “deck of cards” robot—could have pediatric applications. The benefits of his design? The robot itself is small, portable and could act as an extra set of steady, reliable hands for instrument placement which could increase efficiency, potentially reducing procedure time.

“It could be a good fit for pediatric or possibly even prenatal surgical applications,” Dr. Kronrief noted. “I’m looking forward to exploring the possibilities.”

Another pioneer investigating this space is Andreas Melzer, MD, of the Institute for Medical Science and Technology, Dundee, UK . Dr. Melzer has begun discussions with Children’s National radiologists and the Institute’s engineers to develop better programs in pediatrics using interventional magnetic resonance imaging to build more noninvasive procedures using techniques like high-intensity focused ultrasound. Dr. Melzer is helping to develop MR-compatible tools, including ultrasound probes.

“That’s where my interest lies, in using multiple modalities together—for example MR and ultrasound. This is quite important because the promise for these two modalities to have an impact on children is tremendous and would result in more procedures that require little or no exposure to radiation for children.”

Francis S. Collins, MD, PhD, Director of NIH speaks at Children’s National to kickoff Children’s Research and Education Week

Francis S. Collins, MD, PhD, the Director of the National Institutes of Health (NIH) visited Children’s National to speak to a packed room of nurses, physicians, faculty, and staff in honor of Children’s Research and Education Week 2013. Dr. Collins began his talk with the mission of the NIH: “to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability.”

During the talk, Dr. Collins highlighted several of his institutes’ advancements, noting that they have gained exponential knowledge – on the molecular level, going from a few dozen known disease specific genes, to a few thousand. He also outlined President Obama’s new BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative, which aims to map out complex neural circuits using real time imaging technology, and determine how individual brain cells interact.  The program will provide scientists with a better understanding of human behavior and brain development, as well as a clearer picture of common neurological diseases.

Additionally, Dr. Collins addressed the many challenges and bottle necks in the research industry, particularly the lengthy and costly timeline of device development and innovation. Nowhere is this more clear than in the development of treatments and devices for children, a real siloed market, and the subject of an upcoming Sheikh Zayed Institute Symposium.  He reminded the audience about the costliness of successful developments, a major hurdle to overcome.

To help identify those bottlenecks and challenges, the NIH has created the National Center for Advancing Translational Sciences (NCATS) which will – according to their website – “[create] entirely new ways to make the therapeutic development process faster, cheaper, and more accurate.” An example of the work that has come out of NCATS already is a biochip with cells that represent ten different human organs wired with output to give feedback as to the “happiness” or “unhappiness” of the cell after a treatment has been applied, post medicine. Progress made so far has taken less than a year, remarkable progress in such short a time.

The NIH Director also discussed his own work on a pediatric health challenge-- Dr. Collins has worked extensively to understand the genetic mechanisms of a rare childhood disease--Hutchinson-Gilford progeria syndrome – or, progeria which doesn’t appear in children at birth, but begins to show in the first few years of life. Despite normal mental development, the children stop growing, develop orthopaedic problems, and eventually die around age twelve or thirteen of heart attack or stroke.  Unfortunately, progeria is not an inherited condition, making it impossible to predict which child might develop it, and because the life expectancy is so short, studying clinical cases is extremely challenging. Despite this, Dr. Collins’ team discovered the gene mutation that triggers onset of disease (lamin A mutation), and has created preclinical models to study the disease in depth. His passion for pediatrics shined through as he spoke about it—and it is a passion that he shares with the faculty and staff at Children’s National.

The presentation ended with a brief Q & A where a woman tearfully thanked Francis Collins for his work and leadership, as she struggled with another disease that has seen the positive impacts of genetic study—cystic fibrosis. Since its identification, treatments have improved significantly, resulting in her health today. Her story reminded us all that “no matter how long it takes to develop advances in medicine, [it’s worth it to hear that ‘thank you’ from the person affected, even if it’s years later].”

2013 DC STEM Fair: Children's National Medical Center gives awards to student innovators

Woodrow Wilson High School

Sheikh Zayed Institute Awards 3 Junior Scientists!

On Saturday March 23rd, Children’s National Medical Center participated in the DC STEM (Science, Technology, Engineering, Math) Fair held at Woodrow Wilson High School in Washington DC. More than three hundred students from 39 middle and high schools around the district, gathered to showcase more than 200 hundred projects, in categories such as Animal Sciences, Chemistry, Microbiology, Plant Sciences, and Engineering.






While the judges surveyed presentations, students stopped by to test out the Laparoscopic surgery trainer. Matthew Oetgen, MD, Orthopaedics and Sheikh Zayed Institute bioengineer Wen Li coached them through and helped them get a feel for the device. Students reported that the experience was “really cool,” and were extremely focused on performing the best “surgery,” possible.
   



 Around 4pm, judges hunkered down in a classroom to tabulate scores and determine the winners. The Sheikh Zayed Institute judges submitted their Junior Scientist picks for 1st, 2nd, and 3rd place. Children’s National awarded 3 Junior Scientists:

•    1st place ($300) went to Liyana Ido of School Without Walls High School. Liyana’s project was in the medicine and health sciences category, and highlighted the effects of nutritional agents on the NAD+ content of breast milk. Liyana’s work indicated that a nursing mother’s diet could affect her baby’s metabolism.
•    2nd place ($200) went to Anthony Green of Friendship Collegiate Academy. Anthony’s Life Saver project was in the engineering category. This highschooler developed a device that uses both ultrasonic and light sensors to speedily recover and collect objects during a disaster, accident, or explosion.
•    3rd place ($100) went to Lauryn Mitchell of School Without Walls High School. Lauryn’s project was in the cellular and molecular biology category, and questioned Allura Red’s role in the cause of DNA damage. 

Winners: Liyana, Lauryn, and Anthony! 

The winners will tour the Sheikh Zayed Institute, and collect their prizes during their visit.

American College of Sports Medicine names Monica Hubal, PhD, co-Chair of the Molecular and Cellular Regulatory Mechanisms Interest Group

Monica Hubal, PhD, a personalized medicine and systems biology researcher in the Sheikh Zayed Institute, has been appointed co-Chair of the Molecular and Cellular Regulatory Mechanisms (MCRM) Interest Group for the American College of Sports Medicine (ACSM). The purpose of this interest group is to promote and facilitate basic and translational research efforts that identify mechanisms driving disease and how interventions such as exercise confer health benefits at the molecular and cellular levels. The MCRM group also confers research awards to select students that submit the best abstracts each year on basic science topics, helping to defer meeting and travel costs for undergraduate and graduate student researchers and encourage interest in this research areas.

Dr. Hubal is also currently serving on ACSM’s Program Committee, which is responsible for the planning of college's Annual Meeting--the largest gathering of sports medicine professionals of all backgrounds each year.

Dr. Hubal started her career as an exercise physiologist and now uses that background to fuel her genetic research into the causes and treatments for childhood obesity.

The American College of Sports Medicine's Annual Meeting will be held in Indianapolis May 28-June 3. One theme for the meeting is "Exercise is Medicine," focusing on all the ways that exercise improves the health and well being of people starting even at the molecular level, where Dr. Hubal focuses her work, and including the more commonly thought of physical and mental benefits. 

Crowdfunding spotlight: A simple photo can diagnose Down syndrome

A photo can say a thousand words. But can one photo help doctors diagnose Down syndrome?

Researchers at the Sheikh Zayed Institute for Pediatric Surgical Innovation are working on a program that could diagnose Down syndrome immediately after birth with non-invasive automated facial recognition software.

The early detection of Down syndrome has a huge impact on the prevention of potentially life threatening complications including heart conditions. If suspected Down syndrome can be diagnosed early, no matter where a child is geographically located, immediate preventative measures could be introduced that might save his or her life. The current standard, genetic testing, can be severely limited by geography, cost of the testing, and access to physician expertise. If successful, this software could change all of that.

This project is one of four that are taking part in a pilot crowdfunding platform at Children's National. From now until January 31, 2013, anyone with an interest in funding research toward a specific goal in children's health can contribute any dollar amount they see fit, even as little as $1, to the projects they care most about. Please visit www.ChildrensNational.org/crowdfunding to learn more. If you like what you see, please share this link or Like us on Facebook.

What’s working for teens with severe obesity?

A new study online in the Archives of Pediatric and Adolescent Medicine (a JAMA Network publication) finds that although weight-loss surgery for teenagers saw a big jump from 2000 to 2003, after that, the numbers of teens undergoing these procedures plateaued to about 1,000 per year in the United States.

The study, conducted by Children’s National surgeons and experts from several divisions, including lead author and Surgery Research Fellow Deirdre Kelleher, MD, as well as pediatric bariatric surgeon and investigator from the Sheikh Zayed Institute Evan Nadler, MD, and the Chief of the Division of Trauma and Burns at Children’s, Randall Burd, MD, sought to quantify the number of surgeries, the types of surgeries (open vs. minimally invasive), and the demographic of the patients electing to undergo these procedures.

The hard data findings of a plateau in the number of surgical procedures contradicts several high profile commentary pieces citing an increase in the use of bariatric surgery for teens over the last 10 years.

In truth, the data from the Children’s study, which used the AHRQ’s KID database to track inpatient bariatric procedures, finds that, since 2003, the numbers of teens undergoing these procedures has remained static, even while the rate of children with morbid obesity continues to rise.

Interestingly, in the same journal edition, a 3 year longitudinal study out of Sweden found that the more traditional weight-loss interventions involving diet, exercise, and other lifestyle interventions, while successful with teens who have moderate obesity, were not effective at all for adolescents with morbid/severe obesity—the population who has the greatest number of obesity-related comorbidities and would benefit from direct intervention.

“New studies are being published every day, including this one, that show traditional behavioral interventions are not effective for adolescent patients with morbid obesity,” said Dr. Nadler. "If we aren’t treating them successfully with diet and exercise, and they aren’t undergoing surgery, how are we going to help these patients and how will the obesity epidemic end?”

Read the media release at ChildrensNational.org. 

Pediatric health care innovations presented by Children's at World Health Care Congress Middle East

During this week's World Health Care Congress Middle East, Children’s National held a special pediatric session featuring best practices in several key areas of children’s health that will help eliminate unnecessary complex procedures and reduce pain for children. Attendees included leaders in clinical care and policy development from the across the Middle East and Gulf region.The topics were selected based on requests from regional physicians, who were seeking more information about these subjects, including: 





Dr. Atabaki presents research to regional
physicians about assessing traumatic
brain injury in children.


• More precise and effective diagnosis of traumatic head injury, by Shireen Atabaki, MD, MPH, a pediatric emergency medicine specialist and director of Medical Student Education in the Division of Emergency Medicine at Children’s National.
• The reduction of preventable pain during and after surgery through the use of advanced minimally invasive surgical approaches tailored for children, by Craig A. Peters, MD, division chief of Surgical Innovation, Technology, and Translation at Children’s National, and lead of the Innovation and Education Initiative at the Sheikh Zayed Institute.
• The development of new integrated tools to diagnose, treat, and manage ongoing pain in children, by Julia Finkel, MD, associate division chief of Anesthesiology and Pain Medicine and lead investigator of the Pain Medicine Initiative at the Sheikh Zayed Institute.

Dr. Finkel demonstrates the pain algometer
to reporters in Abu Dhabi.

Drs. Finkel and Peters also had a little time to spend with the Abu Dhabi media to talk about the latest work of the Sheikh Zayed Institute in pain medicine and minimally invasive surgery. As this work is largely made possible by the historic gift from the government of Abu Dhabi on behalf of the people, there was much excitement and curiosity from the local media about the institute's recent and upcoming developments.