The Evolution and maturation of the first federally funded PEM national research network - Presented at the Fourth Annual Barsan Emergency Medicine Research Forum

1. Pediatric Emergency Care Applied Research Network (PECARN):
The Evolution and maturation of the first federally funded
PEM national research network
Alexander Rogers, MD
Associate Professor
Emergency Medicine and Pediatrics
Michigan Medicine

2. • Support from the Great Lakes Emergency Medical
Services for Children Research Network (GLEMSCRN) on
behalf of PECARN
• PECARN is supported by the Health Resources and Services Administration (HRSA), Maternal
and Child Health Bureau (MCHB), and Emergency Medical Services for Children (EMSC) through
the following grants: DCC-University of Utah (U03MC00008), GLEMSCRN-Nationwide Children’s
Hospital (U03-MC00003), HOMERUN-Cincinnati Children’s Hospital Medical Center (U03-
MC22684), PEMNEWS-Columbia University Medical Center (U03-MC00007), PRIME-University
of California at Davis Medical Center (U03-MC00001), SW NODE-University of Arizona Health
Sciences Center (U03MC28845), WBCARN-Children’s National Medical Center (U03-MC00006),
and CHaMP-Medical College of Wisconsin (H3MC26201). MCHB/HRSA
Disclosures

3. • PECARN network foundations
• Network structure
• Recently published High-Impact studies
– Probiotics
– DKA
– Febrile infant decision rule
• Future directions
Goals for the talk

4. • Funded since 2001 by
Heath Resources &
Service Administration’s
Emergency Medical
Services for Children
Program
• First federally funded
pediatric emergency
care research network
• U of M’s Dr. Ron Maio
was a founder of
PECARN!
PECARN History

5. Network Map
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■ ●
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● ●
●●
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●
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●= PRIME Node
●= GLEMSCRN Node
= PEM-NEWS Node
= WBCARN Node
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■= Data Coordinating Center
= HOMERUN Node●
= SW Node●
●
= CHaMP Node
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●

6. PECARN
Steering Committee
Data
Coordinating
Center (DCC)
Pediatric Emergency
Medicine Northeast,
West and South
PEM-NEWS
Hospitals of the
Midwest Emergency
Research Node
HOMERUN
Great Lakes
Emergency Medical
Services for Children
Research Network
GLEMSCRN
The Hospitals of the
Southwest Node
SW-Node
Washington, Boston,
Chicago Applied
Research Node
WBCARN
Pediatric Research in
Injuries and Medical
Emergencies
PRIME
PI: Peter Dayan
PI: Rich Ruddy
PI: Rachel Stanley
PI: Kurt Denninghoff
PI: Jim Chamberlain
PI: Nate Kuppermann
PECARN Subcommittees
Protocol Review
and Development
Quality Assurance,
Safety and
Regulatory
Feasibility
and Budget
Grant
Writing and
Publication
HRSA/
MCHB/
EMSC
Federal Project Officer:
Theresa Morrison-
Quinata
Diane Pilkey
PI: Mike Dean
PECARN Organizational Structure
Charlotte, Houston
Milwaukee
Prehospital EMS
Research Node Center
CHaMP
PI: E. Brooke Lerner
Research
Coordinators

7. Concepts, Protocols and Grants 2003-17
107
79
47
43
30
11
0
20
40
60
80
100
120
Protocols, Concepts Grants
Concept Submitted
Concept Approval
Protocol Approved
Grant submitted
Externally Funded
Internally funded

8. External and Internal Funding by year-
Over 100 million dollars in external funding
$0
$2,000,000
$4,000,000
$6,000,000
$8,000,000
$10,000,000
$12,000,000
$14,000,000
$16,000,000
$18,000,000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Infrastructure funding
Total External funding
Suicide, ESETT, THAPCA
$2 for every $1 in infrastructure

9. 2003-2016: Publications by year and Total
1 0 1 3 4 2
9
5 6
11
18
21 20 19
0
20
40
60
80
100
120
140
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Total annual publications
Cumulative totals

10. • PECARN head injury rule is the flagship for the
network (2009, Lancet)
– MEDIC has demonstrated safe decrease in
Head CT use in children with mTBI across
Michigan
• PECARN continues to answer PEM questions
that require a large, high quality network
Recent Accomplishments/It takes a research
Village/The importance of negative trials

11. Probiotics for Acute Gastroenteritis

12. • Clinical Effectiveness and safety profile
– LGG 10^10 CFU BID x 5 days vs placebo
– 971 children 3-48 months with AGE
– 10 PECARN affiliated EDs
Probiotics RCT
Inclusion Criteria
• 3-48 months
• ≥3 diarrheal stools/24h
• <7 days
• Diagnosed with AGE by provider
Exclusion Criteria
• Risk for invasive infection
• Chronic GI disorder
• Pancreatitis
• Bilious emesis
• Hematochezia
• Premature and <6months
• Allergy to LGG
• Allergy to PCN, erythromycin or clindamycin
• No English or Spanish

13. Patient Characteristics
L. rhamnosus
GG
(N = 483)
Placebo
(N = 488)
Overall
(N = 971)
Age: Median (IQR) 1.4 (0.9, 2.4) 1.4 (0.8, 2.3) 1.4 (0.9, 2.3)
Male: N (%) 247 (51.2%) 266 (54.5%) 513 (52.9%)
Baseline MVS: Median (IQR) 12.0 (10.0, 14.0) 12.0 (9.0, 14.0) 12.0 (10.0, 14.0)
0-8 82 (17.5%) 74 (15.4%) 156 (16.4%)
9+ 387 (82.5%) 406 (84.6%) 793 (83.6%)
Diarrhea duration: Median (IQR) 54.3 (29.5, 85.3) 52.4 (28.2, 79.1) 53.2 (29.0, 81.3)
Maximum diarrhea stools in 24 hours: Median
(IQR)
7.0 (5.0, 10.0) 6.0 (4.0, 10.0) 6.0 (5.0, 10.0)
Vomit duration: Median (IQR) 26.6 (0.0, 66.3) 27.9 (3.9, 59.1) 27.5 (2.2, 61.9)
Dehydration
No dehydration (0) 347 (72.3%) 348 (72.3%) 695 (72.3%)
Some dehydration (1-4) 124 (25.8%) 124 (25.8%) 248 (25.8%)
Moderate/Severe dehydration (5-8) 9 (1.9%) 9 (1.9%) 18 (1.9%)
Duration of symptoms less than 48 hours: N
(%)
175 (36.2%) 197 (40.4%) 372 (38.3%)
Treatment: N (%)
Intravenous fluids 59 (12.2%) 69 (14.1%) 128 (13.2%)
Hospital admission 23 (4.8%) 22 (4.5%) 45 (4.6%)

14. Why we have stopped recommending probiotics
In children 3-48 months of age
presenting to the ED with AGE 10^10
CFU of LGG twice daily for five days
demonstrated no evidence of benefit
over placebo.

15. • Patients 0-18
• DKA with pH <7.25 or bicarb < 15
• Blood glucose > 300
• 1389 patients randomized to 0.45 vs. 0.9%
saline and fast vs. slow rehydration
• Measured acute resolution and neurocognitive
outcomes between 2-6 months after
hospitalization
DKA

16. Pediatric DKA

17. Mental Status Changes during DKA episode

18. DKA
So keep doing the right thing….

19. Febrile Infant Decision Rule
• About ½ million ED visits per year
• About 10% will have Serious Bacterial Infection
• Clinical exam/Scoring systems non-discriminatory
• Multiple guidelines exist
• Wide practice variation nationally

20. Rule Derivation

21. How this stacks up…
Rochester
Criteria
1985
Boston
Criteria
Protocol
1992
Philadelphia
Criteria
1993
Pittsburgh
Criteria
(retro)
2001
Swiss
Laboratory
Score
2008
Current
Model
(validation,
application)
# Studied 233 503 747 404 202 1821
Sensitivity
95.7%
(79-99)
N/A
98.5%
(91.8-99.7)
100%
(89.4-100)
94.4%
(84.9-98.1)
97.7%
(91.3-99.6)
Specificity
65%
(58.5-71)
N/A
41.9%
(38.3-45.7)
35%
(30.3-40)
79.7%
(72.5-85.4)
56.4%
(52.9-59.8)
NPV
99.3%
(96.2-99.9)
94.6%
(92.3-96.3)
99.7%
(98.1-99.9)
100%
(96.4-100)
97.5%
(93.0-99.2)
99.6%
(98.3-99.9)
PPV
22.2%
(15.2-31.4)
N/A
13.9%
(11-17.4)
14.8%
(11.1-19.5)
63%
(52.01- 72.7)
19.3%
(15.8-23.3)
LR -
0.07
(0.01-.46)
N/A
0.04
(0.01-.26)
0.03
(0.002-0.54)
0.07
(0.02-0.21)
0.04
(0.01-0.16)
LR +
2.7
(2.2-3.3)
n/A
1.7
(1.6-1.8)
1.52
(1.4-1.65)
4.66
(3.36-6.45)
2.24
(2.06-2.44)

22. • Mental Health
• C-spine injury
• NS vs LR in kids
• TXA for trauma
• Non-traumatic headache imaging decision rule
• Pulmonary Embolism
• EMS (age based dosing)
Current/Futures areas of PECARN focus

23. • PECARN turns 18 this year – but should still be
seen in CES!
Questions