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The ICNA is happy to announce two exciting research opportunities under the ICNA GBOD Research Trainee Fellowship program.The deadline for receipt of applications is April 1, 2015
Eligibility criteria:
1. Must be a member of ICNA
2. Should have completed two years of an accredited child Neurology training program or be within 5 years of completion of their training program
How to apply:
Prospective applicants should write to the respective project supervisors and should provide:
i. an uptodate CV
ii. Reference letters – from program director or division head and two other direct supervisors
iii. Statement regarding motivation for project (300 words)
iv. Evidence of completion of certificate for ethical standards in clinical research or equivalent
v. Potential times of availability for research elective
Selection of applicants will be made by the project supervisors and contingent upon approval by the ICNA Research Task Force.
Final Report:
1. Gabarone Cerebral Palsy Registry-A Pilot Project
2. Demographic profile, Neurological status and Outcome in children with Tubercular meningitis
I. Gabarone Cerebral Palsy Registry-A Pilot Project
PIs/Project Supevisor(s):
Michael Shevell, MD CM, FRCPC, FAAN, FANA
Chairman, Department of Pediatrics
Professor (with Tenure)
Departments of Pediatrics and Neurology/Neurosurgery
McGill University
Guyda Chair in Pediatrics
Pediatrician-in-Chief
Montreal Children's Hospital/
McGill University Health Centre (MUHC)
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr David Bearden MD
The Children's Hospital of Philadelphia
Background, Significance & Rationale: Cerebral Palsy (CP) is conceptualized as a symptom complex that is heterogeneous in all its manifestations; presentation, etiology, evolution, severity, medical and rehabilitation needs, co-morbidities, and outcomes. The common essential feature of CP is an early onset neuromotor impairment that is the result of a non-progressive pathology in the not yet mature brain (Rosenbaum et al, 2007). Roughly half of all children with CP will also experience a non- neuromotor impairment such as cognitive disabilities, epilepsy, speech and language difficulties, primary sensory impairment (i.e. hearing, vision), and behavioural challenges (Shevell, 2009).
CP is the most common physical impairment in pediatrics with a frequency of approximately 2-2.5/1000 live births in Western populations (Kuban& Leviton, 1999). However the majority of the world’s children live in low resource settings. Maternal and early life adversity combine with challenges in health care delivery to ensure that the global preponderance of childhood mortality and morbidity occur in these settings (UNICEF 2005). A case in point is perinatal asphyxia, a recognized causal pathway for a subset of CP.
The WHO estimates that 4 million children annually experience perinatal asphyxia with 99% of these occurrences in low resource settings. Roughly one-quarter of these children will die in the neonatal period while an equivalent fraction will have significant long-term neurodevelopmental impairments including CP (Lawn et al, 2005). Information obtained from high resource settings cannot be extended to low resource settings for reasons of vastly different demographic profiles and health care delivery systems (Thayyil et al, 2009). Improving the health of children in low resource settings optimally is predicated on accurate data. Unfortunately, such data for almost all childhood neurologic disorders in a comprehensive way is lacking (Robertson, 2012).
CP is no exception. While a survey in East Africa indicated that it is the most common neurological impairment encountered by health practitioners ( Mung’ala-Odera et al, 2006), accurate systematic epidemiologic data on its frequency and phenotype has not yet been generated. Anecdotal information from local care providers in low resource settings suggests that potentially preventable etiologies such as perinatal asphyxia, kernicterus, and early postnatal infections are substantial contributors to the CP causal spectrum in contradiction to the situation encountered in high resource settings (Lawn et al, 2009). If confirmed, this would offer the potential for knowledge dissemination efforts that could substantially improve child health in these populations in the near term. However, such efforts to be maximally effective must be based on quantifiable and reliable data capture.
Hypothesis: The frequency of CP will be higher in Gabarone, Botswana and its phenotypic profile (type of CP, functional severity and co-morbidity spectrum) will be different than that in Canada as ascertained utilizing the same mechanisms of case definition and data collection.
Objectives & Specific Aims: Primarily to pilot the procedures and policies of an established population-based CP Registry (Canadian) in Gabarone, Botswana as a first step in objectively ascertaining the epidemiologic profile of this disorder in Botswana (a low resource setting) to be funded in a larger subsequent grant application. While the project by necessity is pilot in orientation, the aims include providing an accurate preliminary assessment of the epidemiology of CP in a geographically well-defined region in a low resource setting that captures CP’s prevalence, spectrum (subtypes, functional severity, co-morbidities), risk factors (antenatal, perinatal, postnatal) and possible etiologies. The information obtained would be of value in optimally targeting later prevention, intervention and rehabilitation strategies to reduce local burdens of care (individual, familial, societal) and improve the health and wellbeing of children with CP and their families in low resource settings.
Research Plan/Methods: The definitions, policies and operational mechanisms of case ascertainment and data capture of the Canadian Multi-Regional CP Registry (Shevell et al, 2009) will be made available into and applied to the geographic confines of the Gabarone Health district in Botswana. There is a relative concentration of both population and neurological and rehabilitation points of care in Gabarone that will facilitate case ascertainment and a consistency of case definition and data capture.
Botswana is a stable democracy with a long history of collaborative international research and high rates of patient participation in research. Universal healthcare is funded enabling patient access to health care and rehabilitation services minimizing potential barriers due to socio-economic status. Each patient has a personalized portable medical record allowing accurate information to be captured on events from the neonatal and early infantile period. In addition, pregnancy and delivery information is recorded on the mother’s personalized record, allowing more accurate classification of antenatal and perinatal risk factor information.
Statistical Analysis: The crude frequency of CP in a defined birth year cohort from Gabarone will be calculated using the number of children with CP identified as the numerator and the number of live births for that year for Gabarone as the denominator. Descriptive analysis will be used to report the phenotype, severity and associated co-morbidities of children with CP in Gabarone. Differences between groups will be explored using student t-tests (continuous variables) or the non-parametric equivalent (on-continuous variables). Descriptive statistics will be used to detail the antepartum, intrapartum and postpartum fetal, maternal and environmental factors evident in Gabarone associated with CP. Data obtained from Gabarone will be compared with that obtained through the Canadian CP Registry.
Budget: Return Airfare: $2200.00. Room and Board $1500/month x 3 months=$4500. Data entry, data storage and analysis costs to be supplied in-kind (i.e. gratis) by the Canadian Multi-Regional CP Registry. The difference between funds obtained through the ICNA Research Fellowship and the costs above will be met through Canadian CP Registry sources. In addition, if the Research Trainee selected for the project is Canadian, then this individual would be eligible for a $8250 (CDN) Practicum stipend from the NeuroDevNet Networks of Centres of Excellence.
References:
Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D et al. (2007) A report: the definition and classification of cerebral palsy April 2006.Dev Med Child Neurol Suppl 109 ():8-14. PMID: 17370477.
Shevell MI, Dagenais L, Hall N, REPACQ CONSORTIUM* (2009) The relationship of cerebral palsy subtype and functional motor impairment: a population-based study.Dev Med Child Neurol 51 (11):872-7. DOI: 10.1111/j.1469-8749.2009.03269.x PMID: 19416339.
Lawn JE et al., Bull WHO 2005; 83: 409-417
Thayyil S, Costello A, Shankaran S, Robertson NJ (2009) Therapeutic hypothermia for neonatal encephalopathy implications for neonatal units in India.Indian Pediatr 46 (4):283-9. PMID:19383987.
Mung'ala-Odera V, Meehan R, Njuguna P, Mturi N, Alcock KJ, Newton CR (2006) Prevalence and risk factors of neurological disability and impairment in children living in rural Kenya.Int J Epidemiol35 (3):683-8. DOI: 10.1093/ije/dyl023 PMID: 16492712.
II. Demographic profile, Neurological status and Outcome in children with Tubercular meningitis[back to top]
PI/Project Supervisor
Prof. Pratibha Singhi
Chief Pediatric Neurology and Neurodevelopment
Advanced Pediatrics Centre
Post Graduate Institute of Medical Education and Research
Chandigarh 160012 India
Phone - 91-172-2755304/2746699
Fax - 91-172-2744401/ 2745078
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Research Site and facilities for trainee: Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research Chandigarh 160012 India
Background and significance: Tubercular meningitis (TBM) is the most severe form of tuberculosis, with high morbidity and mortality rates. Nearly 80% of TBM occur in children less than 5 years of age. The clinical presentation of TBM is non-specific, especially in the early stages of disease, when clinical features alone may not be sufficient enough to distinguish tubercular meningitis from other causes of meningitis. It is often diagnosed when brain damage has already occurred.
Delay in recognition and initiation of therapy leads to poor outcome and significant neurological sequelae. The study will help in delineating the clinical features of TBM and its complications. It will also benefit the trainee by providing experience with a large number of cases of TBM. In addition, he / she will also have the opportunity to see other tropical diseases in the department.
Rationale: India has a large burden of tubercular meningitis and we see a large number of such cases in our department. There are very few studies of childhood tubercular meningitis from India. Hence, we plan to study the demographic profile, clinical features and outcome alongwith predictors of outcome in childhood TBM.
Hypothesis: TBM is a devastating disease of the CNS and survivors are likely to have a poor outcome. Knowledge about the demographic profile and an insight into the early manifestations could help in early detection and treatment and hence improve the outcome of the disease.
Objectives and specific aims: The objective of the study is to get an idea of the demographic profile of TBM in North India. The specific objectives are:
i) To study the clinical features of TBM
ii) To study the radiological features of TBM
iii) To find the outcome and its predictors in children with TBM
Research Plan/epidemiologic study design and Methods
Study design: Retrospective study, chart review and prospective follow up
Study setting: Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh
Study period: January 1 / February 1, 2015 – 31 March 2015
Data analysis: April 2015
Demographic Data: Details of name, age, gender, HIV co-infection, presenting symptoms, history of tubercular contact, immunization history, development history, family socio-economic status will be recorded.
Inclusion criteria: Records of all children admitted from Jan 2010 to Dec 2014 in Advanced Pediatric Centre with possible/ probable/definite diagnosis of TBM, subacute meningitis, chronic meningitis, hydrocephalous and tuberculoma would be screened. Diagnostic criteria as suggested by Marias et al shall be used for ascertaining the diagnosis. The Criteria consists of scoring system consisting of clinical score, CSF score, neuroimaging score and evidence of TB elsewhere in the child.
Exclusion Criteria: Patients with chronic meningitis with proven alternative diagnosis.
Methodology:-The details of patients meeting criteria for enrolment would be screened. Those meeting criteria for TBM would be analyzed in detail. The demographic profile, clinical features, Investigations, details of treatment, complications during the hospital stay, neurological deficits and the outcome at discharge will be analyzed. TBM will be staged using the modified criteria of the British Medical Research Council to determine the severity: stage I TBM (GCS 15 with no focal neurologic signs), stage II TBM (GCS 11–14 or GCS of 15 with focal neurologic deficit), and stage III TBM (GCS <11) (8).
Details of investigations such as cerebrospinal fluid (CSF) study, neuroimaging (CT scan or MRI), Chest X-ray findings, USG head or Abdomen, Gastric Aspirate for AFB, Mantoux test, hemogram, Renal function tests, liver function tests, serum electrolytes (sodium, potassium and chloride) will be recorded.
Follow up: All survivors with a diagnosis of TBM will be called for follow up and their current neurological and developmental status would be determined. Those who are not able to come for follow up will be interviewed in detail via telephone.
Outcome: Clinical outcome will be defined as "good" in case of mild or moderate weakness, isolated or multiple cranial nerve palsies, Generalized development Score of > 50 and complete seizure control on two or less two antiepileptic drugs. Outcome will be classified as "poor" in presence of severe weakness or ataxia, tetraparesis, uncontrolled seizures, need for more than two antiepileptic drugs, generalized development score of < 50 or death. Predictors of outcome will be determined.
Statistical Analysis: Data will be summarized using descriptive statistics. Univariate analysis will be used for correlation between predictors and various outcome measures. Following predictors will be compared. Young age, Stage of TBM, prolonged duration of symptoms, convulsions, headache, posturing, decreased level of consciousness, motor deficits, cranial nerve palsy, brainstem dysfunction, HIV coinfection, hydrocephalus and cerebral infarction on imaging and associated miliary tuberculosis and papilledema .
Budget (including costs for study and room and board for fellow): As permitted under the award ($2,000 for room and board for ~ 2-3 months plus up to $ 2,000 for roundtrip airfare).
References:
Marais S, Thwaites G, Schoeman JF, Török ME, Misra UK, Prasad K et al. (2010) Tuberculous meningitis: a uniform case definition for use in clinical research.Lancet Infect Dis 10 (11):803-12. DOI: 10.1016/S1473-3099(10)70138-9 PMID: 20822958.
British Medical Research Council. Streptomycin treatment of tuberculous meningitis. BMJ1948;1:582-597.