Research Spotlight: SickKids

A new review at SickKids suggests paediatricians should think twice before routinely testing for respiratory viruses

In 2014, more than 2,000 kids who visited SickKids Emergency Department with respiratory symptoms were given an invasive and uncomfortable nasopharyngeal swab test. This is when a doctor or nurse inserts a long swab into the nostril to the back part of the nose to collect a sample of cells. The swabs are sent to the lab to test for six common respiratory viruses, but the results come back the next day, often after patients have already been discharged from the Emergency Department. With no set process for communicating positive or negative results for this test, the results generally did not impact the child’s care.

With an increased emphasis on ‘choosing wisely’ and reducing unnecessary medical tests and therapies across the medical field, paediatricians at The Hospital for Sick Children (SickKids) say it is not good enough to ‘do’ these tests just because we ‘can’. The team examined the benefits and limitations for this specific type of test and reviewed the scientific evidence as to when it is actually helpful in improving patient care. The review, including their recommendations, is published in the July 3 advance online edition of JAMA Pediatrics.

“Just because a test is available doesn’t mean we should automatically order one.”

Most viral respiratory illnesses can be diagnosed clinically based on the child’s symptoms (for example, runny nose, cough, nasal and chest congestion), but with more sophisticated and sensitive tests available, frontline clinicians frequently order tests to identify the specific offending virus.

“While the number of testing options has grown rapidly, the same attention has not been given to deciding how and when these tests can add value to the care of our patients. Just because the test is available, doesn’t mean we should automatically order one, especially since we know that for the majority of healthy children the result will have no impact on their care,” says Dr. Jeremy Friedman, senior investigator of the review and Associate Paediatrician-in-Chief at SickKids.

The review describes some of the common rationales used to justify respiratory viral testing but found poor evidence to support these rationales. Unsupported rationale includes:

  • to reduce the number of lab blood tests and chest x-rays performed, as well as unnecessary antibiotic use
  • to reduce the length of hospital stay
  • to offer prognostic information on length of the illness, and a confirmed diagnostic label for the physician and the family
  • to reduce health care costs

The team emphasized that there are clinical scenarios where respiratory viral testing can inform treatment decisions and improve overall patient care and therefore should be seriously considered. These examples include children with compromised immune systems, those at risk for influenza-related complications, children admitted to intensive care units, and infants with fever younger than three months old.

Healthier, Wealthier, Smarter results

“We hope this review helps health care providers make better decisions and think twice before ‘checking the box’ for a nasopharyngeal swab on the list of possible investigations,” Dr. Peter Gill, lead author of the review and senior paediatric resident at SickKids.

As part of SickKids Choosing Wisely initiatives, SickKids has reduced nasopharyngeal testing for typical respiratory viruses in the Emergency Department by greater than 80 per cent since 2014.

 

Related Stories:

 

SickKids is one of Ontario’s 23 research hospitals that contribute to a healthier, wealthier, smarter province. Read more Research Spotlight posts on our Healthier, Wealthier, Smarter blog or join the conversation about why health research matters for Ontario on Twitter, using the hashtag #onHWS.

 

SickKids researchers sequence genome of Canadian beaver

They were diligent, methodical, meticulous. They overcame obstacles large and small and applied available resources to try to achieve an ambitious goal. When they needed to move beyond existing resources, they pushed the limits and modified them. Channelling some of the most distinctive traits of the quintessentially Canadian symbol they were studying, a team of Canadian scientists has made an indelible mark on the history of this country – and beyond – just in time to kick off the country’s 150th anniversary.

A team of researchers from The Centre for Applied Genomics (TCAG) at The Hospital for Sick Children (SickKids) has successfully sequenced the genome of Castor canadensis – the Canadian beaver. In fact, the beaver in question is none other than Ward, a 10-year-old resident of the Toronto Zoo.  The research, published in the January 16 online edition of G3: Genes|Genomes|Genetics, is a partnership with the Ontario Institute for Cancer Research (OICR), the Royal Ontario Museum (ROM), the University of Toronto and the Toronto Zoo.


Video and feature photo courtesy of SickKids 

Interview with the Researchers

Lead authors, Drs. Stephen Scherer and Si Lok, shed s ome light on why their world-leading research team undertook this unusual project, and how understanding the fundamentals of what makes Ward, Ward, could help scientists advance research into human conditions like autism.

Why did you choose to study the beaver?

S.S.: We could have done this genome research project using DNA from any human or from someone with one of the conditions we study like autism – but by going this route there was even more potential for broader impact! We started exploring our options and realized that our national symbol, the beaver, had not been sequenced yet. This is the most important animal in Canadian history, so to know about its genome allows us to better understand how it all came about: its history, how it relates to its environment. The genome is a starting point.

TCAG sequences about 10,000 genomes a year. One of the areas of focus is how genes play a role in the development of autism in humans. What’s the connection between sequencing a beaver’s genome and helping families understand why autism may affect one child in the family, but not another?

S.S.: There are some families who we know have autism or some other developmental disorder because of the genetics, but we haven’t found the genetic alteration yet. The novel genome-assembly approach that we’ve developed for the beaver project will provide another vantage point.

S.L.: The Human Genome Project led many people to think genetic sequencing is a done deal, but it’s really not. What’s typically done is genome ‘re-sequencing’. The genomes of only a small number of people are actually fully sequenced – less than a dozen in the world. For all the others, to make it cost-effective, we quickly sequence billions of fragments but align them by comparison to a reference genome. It’s really a comparative approach analogous to tracing a picture. But ultimately, we can’t just look at the tracings. We need to see all the underlying unique pieces too, and there are lots of them.

The sequencing of Ward’s genome was done the way we’d eventually like to do everyone’s – it’s called de novo sequencing. It’s a completely original process, which allowed us to build Ward’s unique genome from the ground up, so we would not use any preconception of another genome.

S.S.: Our new genome-assembly technique allows us to find new types of genetic variations we haven’t seen before using the current technologies, so we think our yield in explaining autism will go up. We are already applying the technique in our human sequencing projects, as well as for other animals. It’s very exciting.

Why is the method so important?

S.S.: At TCAG, we’re generating a genome product that is really, really good, but it’s not perfect. To find all the genetic variants we need to fully understand things like cancer or autism, we needed a much better approach.

We were able to take samples from the beaver, find the DNA and put it into the latest genome sequencing machines, which generated the three billion chemical letters of information that comprise the beaver genome. What’s unique about the project is we had to develop some new methods to actually stitch together all of those three billion chemical letters of information into a complete ‘jigsaw puzzle’. At the end of the day, we were able to generate the complete genome sequence of what we believe is the most important animal in Canada.

With new technologies and new sets of analytical experiments we’ve developed here, we can now apply what we learned in the beaver sequencing project to those human sequencing projects we are doing here at the same time.

What does this study show us about the beaver?

S.S.: What we found is that the beaver genome is roughly the same size as the human genome, maybe a little smaller. That’s not really surprising to us; if you look at any mammalian genome sequence – mouse, rat, chimpanzee – and compare it to humans, they’re roughly the same size.

We were able to clearly describe the genes that are important to rodents, and most importantly to the beaver. We identified the genes involved in dentition and enamel deposition, a defining characteristic of rodents, and particularly of beavers. Rodents are classified by their teeth structure, and beavers seem to take this to the extreme because their teeth continuously grow so they can chop down trees. They incorporate a special kind of enamel to strengthen the teeth, and iron, to sharpen them. The mechanism resembles a self-sharpening ice skate, which gets sharper as you skate.

This is really about the power of genetics. We’ve never sequenced any genomes with the quality that we’ve had with the beaver. It’s exciting because it allows us to see some things for the very first time.

Why did you do it now?

S.S.: Dr. Lok and I went to graduate school and did our PhDs at SickKids under Dr. Lap-Chee Tsui, the world-famous Canadian geneticist who discovered the cystic fibrosis gene in 1989. As Canadians, we wanted to give back in some way, above and beyond our typical research. Last year we recognized that the coming sesquicentennial of Canada, new technologies, and our ideas provided the ‘perfect storm’ for us to make a lasting contribution to the scientific world, to our future research, and to the sense of Canadian characteristics of hard work, loyalty, and pride in our heritage. Buy-in from our TCAG team and other Canadian scientists was instantaneous.

Scherer is Director of TCAG and Senior Scientist at SickKids. He is also Director of the McLaughlin Centre and Professor in the Department of Molecular Genetics at the University of Toronto.

Lok is Senior Project Manager and Lead in Technology Development at TCAG.

This study was supported by Genome Canada, Ontario Genomics, Canada Foundation for Innovation, the Government of Ontario, the Lau Family Endowment and SickKids Foundation.

 

Related Stories

Read more Healthier, Wealthier, Smarter blog posts on our Healthier, Wealthier, Smarter site and share your insights on Twitter with the hashtag, #onHWS. To learn more about how health research makes Ontario healthier, wealthier, and smarter, check out our website and our other blog posts and videos.

First-in-Canada: CLIMB program helps kids and teens take steps to holistic care for their minds and hearts

For a child or teen struggling with depression, the world can be a dark place. Depression, combined with the daily ups and downs of school, and life, can become overwhelming, or even paralyzing. Accessing the mental health care they need can be challenging at best. Any concerns about their physical health, as well as warning signs for serious future health problems, are often overlooked.

To address this often-disjointed approach to care, and to try to obtain a clearer picture of the health of the whole child, The Hospital for Sick Children (SickKids) has launched a new program that aims to provide holistic care to children and teens with depression. The first of its kind in Canada, the Children’s Integrated Mood and Body (CLIMB) program provides comprehensive mental health care for paediatric depression, while also screening for risk factors that may result in serious heart and related health problems as the patient grows up. The program is funded by the Medical Psychiatry Alliance, an Ontario initiative dedicated to transforming the delivery of mental health services for patients who are living with both physical and mental health conditions.

Cardiovascular disease is known to be a leading cause of death in individuals with depression, and research has shown that teens with depression are at higher risk of dying younger from cardiovascular causes than their non-depressed peers.

“Youth with mood disorders like depression are often not accessing the care they need. By the time they experience symptoms in adulthood, the window of prevention for cardiovascular problems has long passed,” says Dr. Daphne Korczak, Director of the CLIMB program, Child and Adolescent Psychiatrist and Clinician-Researcher at SickKids, who is also a trained general paediatrician.

CLIMB was designed to integrate physical health care and mental health care by an interdisciplinary team, which includes experts in psychiatry, cardiology, endocrinology, obesity and health systems. In addition to addressing the primary diagnosis of depression, the team aims to identify early signs of cardiovascular disease risk in children and teens. Armed with this information, they can determine opportunities for effective intervention early on, with the hope of reducing the severity of future cardiac problems, or eliminating them altogether.

“SickKids is uniquely positioned to do this because we already have the expertise in all of these related areas,” Korczak explains. The program is both a clinical initiative and a three-year research project. A clinical research registry is in development, through which clinical assessments, cardiometabolic markers, treatments and depression outcomes can be examined.  When complete, all CLIMB patients will be invited to participate. This research, Korczak hopes, will be an important step toward addressing a critical gap in scientific knowledge about how and when depression first presents an increased risk of cardiovascular disease. The team is also studying how early treatment of depression can impact cardiovascular risk.

“The CLIMB program will address this important question head-on, and pave the way for us to ensure that youth with mental health issues have excellent physical health as well. Recent research has suggested that youth with mental illness may have a higher chance of having risk factors for adult heart disease,” says CLIMB team Dr. Brian McCrindle, Staff Cardiologist and Section Head of Preventative Cardiology at SickKids and Professor of Paediatrics at the University of Toronto.

One in 15 Canadian children and teens are diagnosed with depression every year. CLIMB began seeing patients in June and feedback from families and clinicians alike has been positive so far.

“By bringing together experts in both mental and physical health, we can look more broadly at what’s going on for the child or youth as a whole, and be better equipped to help them thrive in the future,” says Korczak, who is also Assistant Professor of Psychiatry at the University of Toronto.

CLIMB is one of several innovative pilot programs rolling out at SickKids under the mandate of the Medical Psychiatry Alliance, a collaborative partnership between The Centre for Addiction and Mental Health, SickKids, Trillium Health Partners and the University of Toronto, in conjunction with the Ministry of Health and Long-Term Care and an anonymous donor.

Originally published on the SickKids website, this research story is an example of how SickKids is contributing to making Ontario Healthier, Wealthier and Smarter. www.healthierwealthiersmarter.ca.

 

Related Stories:

 

RESEARCH SPOTLIGHT: CHEO

Patient-oriented Research on Children and Youth

By Dr. Martin Osmond
CEO and Scientific Director, CHEO Research Institute (Ottawa, ON)

As part of the federal government’s recent strategy on patient-oriented research (SPOR), the Canadian Institutes of Health Research (CIHR) and the Government of Ontario have invested in a Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit in Ontario. The goal of the Ontario SPOR SUPPORT unit (OSSU) is to promote and support high quality patient-oriented research in Ontario that will contribute directly to health system and patient care improvements.

I want to take a moment to shine a spotlight on one of twelve centres that make up the Ontario Child Health SUPPORT Unit (OCHSU), an arm of the Ontario SPOR SUPPORT unit. OCHSU’s mandate is to create better health outcomes for children and youth. The Children’s Hospital of Eastern Ontario (CHEO) is proud to be co-leading this collaboration of pediatric academic sites across Ontario along with the Hospital for Sick Children (SickKids). Our extended network partner sites include McMaster Children’s Hospital, London Health Sciences Centre, Kingston General Hospital, and Holland Bloorview Kids Rehabilitation Hospital.

The goal is to assist researchers in solving health problems that are important to children and their families. OCHSU does this by providing an integrated, province-wide clinical research infrastructure for child health researchers. By leveraging a ‘Clinical Trial hub’ at SickKids and a ‘Data Research and Database Management hub’ at CHEO, we engage our network partners to conduct world-class pediatric clinical trials that have the potential to transform our province’s healthcare system through high-impact, patient-oriented research for children and youth.

Our aim is to optimize children’s health outcomes by enhancing the efficiency, quality, and standards of child health clinical research across Ontario. We also promote the knowledge translation of clinical research into practice and policy, all with the aim of delivering cost-effective and safe healthcare.

Sounds good, but how do we do this?

We provide research consulting support and services to investigators who wish to address important questions on the health and wellbeing of Ontario’s children. Current studies include new approaches for treating concussion, novel supports for the transitioning of care for teens reaching adulthood, and determining safety profiles for drugs used frequently in children.

As part of the Data Research and Database Management hub, OCHSU experts at CHEO offer services related to clinical and health administrative data research and solutions for high quality data management in clinical trials.

As part of the Clinical Trial hub at SickKids, OCHSU experts offer support in areas such as clinical trial methods, biostatistics, health economics, and regulatory compliance.

Both hubs encourage and facilitate research opportunities where patients are involved in all stages of the design and conduct of the studies. In addition, we encourage projects that catalyze and build new stakeholder relationships, encourage new research collaboration, build capacity in child health clinical research, lead to healthcare system transformation, and develop new models for child health research.

Our collective goal is to enact major changes in policy that will improve outcomes and generate significant cost savings by the widespread implementation of the results of our research. By providing scientifically excellent, high-impact projects that tackle areas of major burden in child health, OCHSU will lead in the development of innovative research methods and will set the standards for child health research.

CHEO is one of Ontario’s 24 research hospitals that contribute to a healthier, wealthier, smarter province. Look for other RESEARCH SPOTLIGHT posts on our Healthier, Wealthier, Smarter blog. To learn more about what’s needed to support Ontario’s health research enterprise, download our Policy Platform.

RESEARCH SPOTLIGHT: SickKids

Point-of-care ultrasound leads to more efficient and accurate diagnoses in SickKids emergency

They’re calling it ‘the stethoscope of the future’. A portable technology called point-of-care ultrasound is helping doctors at The Hospital for Sick Children (SickKids) provide better and more efficient bedside care in the emergency department, and it’s having a huge impact.

Point-of-care ultrasound is used in about 25 to 30 per cent of the cases coming through SickKids’ Emergency Department. “Since using ultrasound at the bedside, I find I’m using my stethoscope less. We’re identifying medical issues more efficiently and accurately which is essentially leading to better decision-making, better care for our patients, and even a reduction in ED wait times for some patients,” says Dr. Mark Tessaro, Staff Physician in Paediatric Emergency Medicine and Research Lead in the point-of-care ultrasound program at SickKids.

Ultrasound is a safe and radiation-free medical device that uses sound waves to produce images of what’s going on inside the body.

The Paediatric Emergency Medicine point-of-care ultrasound program was launched at SickKids in 2011. The goal was to improve the care of injured and ill children through a new application of this reliable and well-established tool. SickKids is Canada’s only training centre for paediatric point-of-care ultrasound and in five years, 10 fellows have been trained and have subsequently brought their expertise and experience to other hospitals across the country and internationally.

“It helps to confirm a diagnosis much faster than before”

The applications for point-of-care ultrasound in the ED are far reaching. It enables doctors to detect internal bleeding, cardiac, and/or intestinal problems, it can uncover foreign bodies, an abscess that needs to be drained, a twisted teste or ovary, and even retinal detachment in the eye, which is very challenging to identify in children. It also helps with procedures like inserting an airway tube, or delivering an anaesthetic injection (nerve block) for example.

“There is no doubt in my mind that point-of-care ultrasound has improved the care I provide my patients. Before I began using it, I would order more tests, which later proved to be unnecessary, and spend more time doing physical exams in efforts to figure out the root problem,” says Dr. Charisse Kwan, Staff Physician in Paediatric Emergency Medicine and Education Lead in the point-of-care ultrasound program at SickKids. “It doesn’t replace the physical exam but in some ways gives us ‘magic fingers’ that enhance the physical exam and helps to confirm a diagnosis much faster than before.”

90 minutes later, 12-year-old Hannah was back on Snapchat

In mid-December, after several days of illness and an outpatient chest X-ray that suggested pneumonia, Hannah Diamond, 12, was rushed to SickKids’ Emergency Department when her fever spiked to 40 C, her lips suddenly turned blue, and she began shaking and shivering. Dr. Tessaro was working that evening, and within five minutes of Hannah’s arrival at SickKids’ Emergency Department, Dr. Tessaro told Hannah and her mom, Sari, that he’d like to do an ultrasound at the bedside to get a better picture of any potential complications that could have caused Hannah’s sudden distress. Almost immediately, Tessaro was able to rule out serious complications like fluid on the lungs, and he and the Diamond family had their answer – it was a straightforward bacterial pneumonia.

“Having a clear picture of what we were dealing with meant I didn’t need to order the usual chest X-ray, avoiding unnecessary radiation exposure for Hannah,” says Tessaro, who quickly prescribed Hannah IV antibiotics and acetaminophen.

Within 90 minutes, Hannah was back on her smartphone, texting friends about her adventure in the Emergency Department and posting photos and updates to Snapchat. About two hours later, she was discharged, and the next morning, Hannah woke up fever free for the first time in a week.

The emergency team has multiple examples of how the use of point-of-care ultrasound in the Emergency Department is improving care and has even led to quick detection of rare congenital diseases, heart conditions, and cancers that likely would have taken many emergency and specialist visits before a diagnosis was uncovered.

“As ED doctors we have a responsibility to assess patients quickly and detect problems accurately, in all areas of the body. Point-of-care ultrasound is helping us do that better,” says Tessaro.

The goal is to have virtually all SickKids staff emergency medicine physicians fully trained to use point-of-care ultrasound. Currently five are fully trained.

Drs. Tessaro and Kwan are Assistant Professors in the Department of Paediatrics at the University of Toronto.

 

SickKids is one of Ontario’s 24 research hospitals that contribute to a healthier, wealthier, smarter province. Look for other RESEARCH SPOTLIGHT posts on our Healthier, Wealthier, Smarter blog. To learn more about what’s needed to support Ontario’s health research enterprise, download our Policy Platform.

 

 

Building a SMARTER Ontario: Dr. Janet Rossant’s Story

Ontario research hospitals contribute to a smarter Ontario by attracting, training and retaining some of the world’s most highly skilled researchers that help to establish our province as a destination for discovery and research development while building our knowledge-economy. Among these researchers is Dr. Janet Rossant, who proved the pluripotency of embryonic stem cells, in collaboration with Dr. Andras Nagy, in 1993 right here in Ontario.

Continue reading “Building a SMARTER Ontario: Dr. Janet Rossant’s Story”

Groundbreaking Health Research is Happening Here

Research hospitals play a leading role in Ontario’s knowledge-based economy. To demonstrate the world-class research happening right here in our province, CAHO was delighted to host Deputy Minister of Research and Innovation, Giles Gherson, and Director Allison Barr on a 3-stop Innovation Tour to research labs at The Hospital for Sick Children (SickKids) and University Health Network (UHN). Continue reading “Groundbreaking Health Research is Happening Here”