Cumberland Pediatric Foundation

Connecting the Pediatric Community since 1994

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Socks Blog:Personalized Medicine

Personalization: From Your Monogram to Your Medicine

Madi Shultz, SOCKs Communications Fellow

 

What is personalized medicine?

 

Personalized Medicine (PM) is a model that is centered on individualization of health care practices, products, and strategies to meet patient needs. The intent of the movement toward personalized care is to move toward a more patient-centered attitude that results in predictable and powerful medicine. With a growing understanding of human genetics, effective drug prescription, and safer medical treatments, personalized medicine uses collaborative work with researchers, health care providers, advocacy groups, diagnostic companies, informatics companies, biopharmaceutical companies, and, most importantly, patients to design a reliable medical treatment program.

 

What personalized medicine treatments are already being utilized?

 

Pediatric Eye Cancer:

The Children’s Hospital of Los Angeles (CHLA) has partnered with the Vision Center and Department of Pathology and Laboratory Medicine at CHLA to develop a new gene-sequencing test that will identify all medical changes related to the retinoblastoma gene in eye cancer patients. Using a patient’s human genome recorded at birth, sequencing technology, and bioinformatics, CHLA will use a “bench-to-bedside” mentality to prevent rather than react to cancerous cell formation on the eye.

 

Melanoma:

BRAF is the human gene that is responsible for producing a protein called B-Raf, which helps sends signals inside cells to direct cell growth and is shown to be in mutated cells. A drug called vemurafenib, a B-Raf protein inhibitor, and the companion Mutation Test were approved for the management of late stage melanoma in 2011 working only for patients with the BRAF mutation (60% of patients).

 

Cardiac Care:

Clopidogrel (Plavix) is an antiplatelet drug prescribed to pediatric patients with severe heart disease to prevent life-threatening blood clots from forming following cardiac procedures. However, about 20% of the global population carries a gene variation that greatly reduces the effectiveness of Plavix, at times resulting in blood clotting even while taking the medication. To combat this issue, PREDICT was created using genetic testing to locate and improve care for heart patients. Since knowledge of best care practice is known prior to the medicine being prescribed, doctors are able to tell the “poor responders” from the “positive responders” in order to prevent blood clots from forming.

 

What does personalized medicine look like in practice?

 

An example of personalized medicine in practice started at Monroe Carrell Junior Children’s Hospital at Vanderbilt in March of 2014 and has continued since then. The PM strategy is a multidisciplinary surgical epilepsy conference designed to combine areas of neuroscience, imaging, neuropsychology, and neurosurgery to coordinate patient care. Treating clinicians refer patients to the conference and present the patient’s complete epileptic history including current treatment techniques and a video of the patient’s seizure to the quorum. After presenting family, socio-demographic, and likelihood of proper care information, the quorum deliberates and personalized medical care is decided between the following:

1) neurosurgical intervention

2) alteration of drug regimens for continued medical treatment

3) continued seizure monitoring with further evaluation by the quorum in the future 

Once the decision is made, the treating clinician continues personalized medical plans in the hope of reaching seizure-free status and full patient-centered success. 

November News

Man the shots and mind the mist, November is here and the Flu has bliss! Guard your cells and do not kiss, meningitis can be missed! 
Welcome November, your colds we do remember, but this year we’ll be well enough to last the winter! 

 

What Should I be aware of this November?

Improve Mental Health this November

So many studies have shown how having an “attitude of gratitude” improves mental health! It improves sleep, grades, relationships, etc.

So how can you implement this attitude in your patients? 

Simple! Just ask them what they’re thankful for.
You can phrase it in many different ways, just planting that seed of thought can have a large impact.

A few ways to ask or lead into the topic:

1. Bring up a material possession they’re wearing/holding: “Hey Sally! Wow those are great shoes, do you like them? I’m pretty thankful for my shoes, they’re important!” 
2. Point out how healthy they are: “Woah, Tom! You are getting so big and strong, I bet you’re pretty thankful for that”
3. Tie it to the upcoming holiday: “Sarah, did you know it’s November? Thanksgiving is soon! What are you thankful for?”
4. In your waiting room have coloring pages prompting the patient to “Draw a picture of something they’re thankful for” then ask them if they drew anything while they were waiting and if so, what?
 

Tip: If you have a patient displaying signs of poor mental/behavioral health, an easy excersise for the guardians might be to have them write/draw a picture of one thing they’re thankful for every day. 

 

Interested in reading more about how gratitude can improve health? Follow the links below for more articles:

http://www.healthline.com/health/depression/giving-thanks#2

http://www.forbes.com/sites/amymorin/2014/11/23/7-scientifically-proven-benefits-of-gratitude-that-will-motivate-you-to-give-thanks-year-round/

http://www.huffingtonpost.com/2014/07/21/gratitude-healthy-benefits_n_2147182.html

https://www.psychologytoday.com/blog/prefrontal-nudity/201211/the-grateful-brain

Don’t Forget to Check!

Screening a healthcare employee or third party vendor includes an initial OIG background check of the List of Excluded Individuals and Entities (LEIE). This should be done prior to the hiring of or commencement of billing for the services or items purchased from a third party vendor.

How often should a healthcare organization check the exclusion list after hire or contracting with a third party?

To Read the Full Article from ProviderTrust Click here: NOTICE: OIG Background Check Requires OIG Exclusion Monthly Monitoring

Understand Smoking

Behavioral Health

Are your patients exposed to second hand smoke? Are your older patients showing signs of first hand smoke? This article explores the psychology of smoking and how there is probably a behavioral disorder to treat. Read more here

Did you know?

Approximately one-quarter of Tennesseans currently use tobacco products; the number of users of electronic nicotine delivery systems is not yet known. Those seeking help ending their nicotine addictions can find assistance at the toll-free Tennessee Tobacco QuitLine, 1-800-QUIT-NOW (1-800-784-8669). 

Latest news from The IAC and SOCKS

This week’s CPF picks from the IAC News
 
CDC updates recommendation for timing of postvaccination serologic testing of infants born to HBsAg-positive women
An estimated 25,000 infants are born to HBV-positive mothers each year in the United States. However, post-exposure prophylaxis (PEP) is highly effective in preventing perinatal HBV transmission; only 1 percent of infants receiving PEP develop infection. Infants born to HBV-infected mothers should receive hepatitis B vaccine (consisting of a 3- or 4-dose series) and hepatitis B immune globulin within 12 hours of birth to prevent perinatal HBV transmission. In order to determine whether the infant requires revaccination, [postvaccination serologic testing] PVST was previously recommended at age 9–18 months. Because new evidence suggests that hepatitis B antibody levels decline following vaccination, CDC now recommends that PVST take place earlier—at age 9–12 months, or 1–2 months after the final dose of the hepatitis B vaccine series—in order to ensure antibodies are detected. Benefits to this shortened interval include a reduction in the time that non-responders are at risk for transmission from close contacts with HBV infection, opportunity for prompt revaccination when needed, and conservation of public health resources. Additionally, the authors note that a shortened interval might increase adherence with recommendations for timely completion of PVST. 
 
CDC study finds anaphylactic reactions rare after immunization
A recently published CDC-authored study based on a large population group that received currently used vaccines confirmed the rarity of anaphylaxis after vaccination. Risk of Anaphylaxis after Vaccination in Children and Adults was published online on October 7 in the Journal of Allergy and Clinical Immunology. The “Abstract” is reprinted below. Background Anaphylaxis is a potentially life-threatening allergic reaction. The risk of anaphylaxis after vaccination has not been well described in adults or with newer vaccines in children. Objective We sought to estimate the incidence of anaphylaxis after vaccines and describe the demographic and clinical characteristics of confirmed cases of anaphylaxis. Methods Using health care data from the Vaccine Safety Datalink, we determined rates of anaphylaxis after vaccination in children and adults. We first identified all patients with a vaccination record from January 2009 through December 2011 and used diagnostic and procedure codes to identify potential anaphylaxis cases. Medical records of potential cases were reviewed. Confirmed cases met the Brighton Collaboration definition for anaphylaxis and had to be determined to be vaccine triggered. We calculated the incidence of anaphylaxis after all vaccines combined and for selected individual vaccines. Results We identified 33 confirmed vaccine-triggered anaphylaxis cases that occurred after 25,173,965 vaccine doses. The rate of anaphylaxis was 1.31 (95% CI, 0.90–1.84) per million vaccine doses. The incidence did not vary significantly by age, and there was a nonsignificant female predominance. Vaccine-specific rates included 1.35 (95% CI, 0.65–2.47) per million doses for inactivated trivalent influenza vaccine (10 cases, 7,434,628 doses given alone) and 1.83 (95% CI, 0.22–6.63) per million doses for inactivated monovalent influenza vaccine (2 cases, 1,090,279 doses given alone). The onset of symptoms among cases was within 30 minutes (8 cases), 30 to less than 120 minutes (8 cases), 2 to less than 4 hours (10 cases), 4 to 8 hours (2 cases), the next day (1 case), and not documented (4 cases). Conclusion Anaphylaxis after vaccination is rare in all age groups. Despite its rarity, anaphylaxis is a potentially life-threatening medical emergency that vaccine providers need to be prepared to treat. 
 
WHO announces recommended composition of influenza virus vaccines for use in the 2016 southern hemisphere influenza season
The World Health Organization (WHO) recently released information about the composition of the strains that will be used for seasonal influenza vaccination in the southern hemisphere in 2016. It is recommended that trivalent vaccines for use in the 2016 influenza season (southern hemisphere winter) contain the following:
 An A/California/7/2009 (H1N1)pdm09-like virus
 An A/Hong Kong/4801/2014 (H3N2)-like virus
 A B/Brisbane/60/2008-like virus
It is recommended that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus. Read WHO’s Recommended composition of influenza virus vaccines for use in the 2016 southern hemisphere influenza season. 
 
Question of the Week
If a child only received a half dose of live attenuated influenza vaccine (LAIV, FluMist, MedImmune), I understand they are not considered immunized. Can the child receive inactivated influenza vaccine (IIV) on the same day?
You are correct that a half dose of LAIV (or any other vaccine) is a non-standard dose and should not be counted. If you weren’t able to give the second half of the LAIV at that same appointment, you will need to provide another full dose of influenza vaccine at another visit. If you want to try using a different type of vaccine, you can give IIV any time after the partial dose of LAIV. If you want to give LAIV again, you should wait four weeks because it is a live vaccine.
 
New Article from SOCKS!
 
Putting the Pieces Together: Endoscopic vs. Traditional Treatment of Craniosynostosis
The skull of the human brain is made of many bones that fit together like an anatomical jigsaw puzzle. Normally, the pieces gradually fuse together over stages of prenatal and childhood development. However, in approximately one out of every 2,200 live births, craniosynostosis occurs. Craniosynostosis is a premature fusion of bones in the skull, often before a baby is born. In this case, the remaining open sutures must compensate for the closed parts of the skull resulting in deformities of the head. If not treated in a timely manner, the closed portions of the skull can prevent the brain from developing properly, at times even affecting normal childhood maturing processes.
Previously, the main method of treatment was to make an incision from ear to ear on an infant’s scalp, totally or partially removing skull pieces, and placing them back together using additional prosthetic materials as necessary. Typically taking three to seven hours with a three to five day recovery, postoperative swelling and discomfort was present. Although the surgery produced good results, another goal of physicians was to reduce pain, hospitalization time, and blood loss.
With that goal in mind, an endoscopic assisted repair for craniosynostosis treatment has now become more prevalent in patients less than 6 months old. Utilizing a small endoscope, doctors now use one or two small incisions, approximately 1.5 inches long. Instead of physically re-structuring the skull with additional materials, the endoscopic surgery removes small pieces of fused bone, leaves space for the brain to grow, and uses a post-operative, custom-made helmet to ensure the protection and correct growth of an infant’s head. The patient wears this helmet for up to a year in order for the skull to grow according to the structure of the helmet.
As both procedures offer positive results with the intention of giving the brain room to grow and restoring a patient’s head to a normal shape, researchers were compelled to measure the effectiveness of both surgeries. In a retrospective studies published in the Journal of Craniofacial Surgery in 2013 and Journal of Neurosurgery: Pediatrics in 2014, patients underwent the craniosynostosis repair either by traditional or endoscopic means, comparing operating room times, blood loss, volume of transfused blood, length of hospital stay, and overall costs. Outcomes showed that the endoscopic procedure resulted in shorter operating room times, lower estimated blood loss, less transfused blood, shorter hospital stays, and decreased costs. The studies also recognized issues with compliance in wearing the molded helmet as well as minor skin breakdown after extended helmet use. Therefore, the research concluded that, with compliant patients, the endoscopic procedure was a viable option for craniosynostosis repair. These studies also illustrate the importance of recognizing craniosynostosis early, as the endoscopic repair is only considered in patients less than 6 months old.
Overall, both procedures have produced positive results. However, the endoscopic procedure seems to fit all the pieces together for a cost-effective, safe surgery to ensure a better future for a patient’s neurological development.

 

Vision Study Wrap Up

CPF joined the Welch-Allyn PediaVision study with Dr. Donahue when the need for more effective vision screening was noticed. The purpose of the study was to be the first large scale, multi-center evaluation of photoscreening in the medical home. 

CPF members were very eager to participate in this study; 12 CPF community sites participated and worked very hard to record their referrals and to promote the need for vision screening. 

A huge thank you to Dr. Sean Donahue, the Vanderbilt Eye Institute, Sandy Owings, Janet Cates, Jana Bregman, and the following participating practices:
Nurture Pediatrics
The Pediatric Center of Tullahoma
The Children’s Clinic of Nashville
Rivergate Pediatrics
Children’s Clinic East-Mt. Juliet, Hermitage, Lebanon
Brentwood Pediatrics
Capstone Pediatrics-Southern Hills, Centennial, Lebanon
Meharry Pediatric Group

We are so delighted to have been a part of this ground-breaking study and look forward to following how it impacts our community!