Close
Enter your
text here

In Brief

For AYA Females With Rhabdomyosarcoma, Consider Routine Examination or Imaging of Breasts
 For AYA Females With Rhabdomyosarcoma, Consider Routine Examination or Imaging of Breasts 150 150 Abbie Miller
By: Abbie Miller

Rhabdomyosarcoma with breast involvement is found almost exclusively in females. A recent case series highlights the need for guidelines for follow-up imaging. Rhabdomyosarcoma (RMS) is a soft tissue sarcoma associated with metastasis and inferior outcomes in adolescent and young adult (AYA) patients (those with cancer diagnosis at age 15-39 years). Metastases to the breast have…

Hospitals Should Use Genotyping to Monitor Bacterial Infections
 Hospitals Should Use Genotyping to Monitor Bacterial Infections 150 150 Kevin Mayhood
By: Kevin Mayhood

A team led by a pulmonologist-researcher found that in a children’s hospital, an unexpected pathogen emerges as a common cause of infection. The bacteria Acinetobacter baumannii is a widely-reported cause of healthcare-associated infections, particularly in adult intensive care units in developing countries. But a retrospective study of isolated cases at Nationwide Children’s Hospital found that Acinetobacter pittii recently emerged…

Why Patients With Diabetes Have More UTIs
 Why Patients With Diabetes Have More UTIs 150 150 Mary Bates, PhD
By: Mary Bates, PhD

Insulin regulates an antimicrobial peptide that is suppressed in patients with diabetes. A recent study led by clinicians and researchers at Nationwide Children’s Hospital reports a potential explanation for why urinary tract infections (UTIs) are so common in patients with diabetes – insulin regulates an antimicrobial peptide (AMP) that is suppressed in those patients. Patients…

Local Learning Health System Model Demonstrates High-Quality Patient Care While Reducing Costs
 Local Learning Health System Model Demonstrates High-Quality Patient Care While Reducing Costs 150 150 Jan Arthur
By: Jan Arthur

Providing high-quality patient care while reducing costs is a significant goal in the current health care reform environment. The Institute of Medicine has specifically called for the establishment of “learning health systems” to address this challenge. In a learning health system, the electronic health record is utilized to drive research and personalized treatments based on…

Many Respiratory Pathogens, One Test: The Respiratory Infection Array
 Many Respiratory Pathogens, One Test: The Respiratory Infection Array 150 150 Jeb Phillips
By: Jeb Phillips

A multiplex polymerase chain reaction assay newly available for outpatients is faster and more comprehensive than conventional testing for causes of upper respiratory infection. ‘Tis the season for coughs, runny noses and the challenge of trying to pinpoint which pathogen is causing your patient’s particular upper respiratory infection. Clinical presentations are similar for a number…

Promising Practices and Patient-Centered Medical Neighborhoods for Childhood Obesity
 Promising Practices and Patient-Centered Medical Neighborhoods for Childhood Obesity 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

An algorithm for assessment and management of childhood obesity, along with patient-centered medical neighborhoods, provides avenues for comprehensive weight management for children 2 years and older. Although childhood obesity affects 17 percent of children in the United States, and nearly one-quarter of these children are overweight, only a few centers in the country provide evidence-based…

New App Enables Families and Researchers to Track Seizures With an Apple Watch
 New App Enables Families and Researchers to Track Seizures With an Apple Watch 150 150 Gina Bericchia
By: Gina Bericchia

Could a wearable app help children with seizures? With the launch of the Track It! app for Apple Watch, that’s what researchers at Nationwide Children’s Hospital are hoping to find out. Nationwide Children’s Hospital and SeizureTracker.com recently introduced a new wearable app to help track seizures called Track It!, which free to download for the Apple Watch in the…

Should Melatonin Be Used To Treat Childhood Insomnia?
 Should Melatonin Be Used To Treat Childhood Insomnia? 150 150 Mark Splaingard, MD
By: Mark Splaingard, MD

Mark L. Splaingard, MD, director of the Sleep Disorders Center at Nationwide Children’s Hospital, answers a question often asked by primary care providers. With some reports that insomnia symptoms are experienced by 20 percent or more of children, health care providers (and parents) often want to know if melatonin is appropriate to use in the…

Understanding Stress Experienced by Survivors of Congenital Heart Disease
 Understanding Stress Experienced by Survivors of Congenital Heart Disease 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

For adolescent and adult survivors of congenital heart disease, how they perceive disease-related stress has a key connection to how they report health outcomes, such as quality of life and emotional well-being. Researchers at Nationwide Children’s Hospital are the first to systematically identify different types of disease-related stress experienced by survivors of congenital heart disease,…

Two Genes Linked to Postpartum Immunity Revival in Women With Persistent Hepatitis C
 Two Genes Linked to Postpartum Immunity Revival in Women With Persistent Hepatitis C 150 150 Kevin Mayhood
By: Kevin Mayhood

Research may provide a model for identifying immune factors needed to control chronic infections. Alternative forms of two genes are associated with a boost in immunity to hepatitis C after childbirth, a study led by a Nationwide Children’s Hospital physician-researcher shows. At three months postpartum, the number of viruses circulating in the blood declined sharply…

How to Reduce Necrotizing Enterocolitis in the NICU
 How to Reduce Necrotizing Enterocolitis in the NICU 150 150 Jeb Phillips
By: Jeb Phillips

A QI project with simple, inexpensive interventions significantly lowered the NEC rate in one of the country’s largest neonatal units. In 2011, a quality improvement team at Nationwide Children’s Hospital developed a short list of simple, economical strategies to limit necrotizing enterocolitis (NEC), one of the leading causes of morbidity and mortality in its associated…

What Do Space Rocks Have to Do With Preterm Birth?
 What Do Space Rocks Have to Do With Preterm Birth? 150 150 Abbie Miller
By: Abbie Miller

A brief history of nanobacteria and their implications for human health. I remember when nanobacteria were a really big deal. Press-conference-by-POTUS-about-evidence-of-extraterrestrial-life-level big deal. I hadn’t thought much about them until recently, when they made a surprise appearance in a presentation on idiopathic preterm birth by Irina Buhimschi, MD, director of the Center for Perinatal Research at The…

New Study Points to a Possible Cause of Many Preterm Births
 New Study Points to a Possible Cause of Many Preterm Births 150 150 Jeb Phillips
By: Jeb Phillips

The discovery that small calcium deposits in fetal membranes may lead to a mother’s water breaking prematurely suggests that dietary or other interventions could prevent those preterm births. Most spontaneous preterm births do not have causes that are easy to identify. Physicians frequently have not known why uterine contractions begin weeks earlier than they should,…

Should Hormone Therapy be Considered for Inappropriate Sexual Behavior in Adolescents With Autism Spectrum Disorder?
 Should Hormone Therapy be Considered for Inappropriate Sexual Behavior in Adolescents With Autism Spectrum Disorder? 150 150 Jeb Phillips
By: Jeb Phillips

Families worry when children with autism spectrum disorder display inappropriate sexual behaviors, but specialists say hormonal suppression should not be the first-line approach. Leena Nahata, MD, a pediatric endocrinologist at Nationwide Children’s Hospital, has seen this kind of case in her own practice, so she suspects that other specialists have as well: An adolescent boy with autism…

From Military Zones to Pediatric Trauma Centers, Implementing Massive Transfusion Protocols
 From Military Zones to Pediatric Trauma Centers, Implementing Massive Transfusion Protocols 150 150 Abbie Miller
By: Abbie Miller

While military and adult research has shown massive transfusion protocols to be lifesaving, implementation and validation in pediatrics lags. When someone is critically injured with life-threatening bleeding, the primary objective of the care team is to stop the bleeding and replace the lost blood. Historically, children in this situation were administered red blood cells (RBCs)…

Solving the Problem of Managing Big Genomic Data
 Solving the Problem of Managing Big Genomic Data 150 150 Abbie Miller
By: Abbie Miller

Researchers at Nationwide Children’s Hospital complete a first-of-its-kind project to evaluate a large-scale genomic data management system on the scale of up to one million genomes. The influx of genomics data resulting from the increasing affordability of whole exome/genome sequencing and President Obama’s Precision Medicine Initiative requires a novel technological solution to data storage, communication…

Diagnosing GERD in Neonates? Be Cautious
 Diagnosing GERD in Neonates? Be Cautious 150 150 Jeb Phillips
By: Jeb Phillips

Gastroesophageal reflux disease is likely over-diagnosed in neonates, leading to unnecessary and harmful treatment. Approximately 10 percent of infants born preterm in the United States are diagnosed with gastroesophageal reflux disease (GERD). But it’s almost certain that not all of those babies actually have GERD, say neonatologists at Nationwide Children’s Hospital. The probable over diagnosis leads to…

A New Use for Kangaroo Care
 A New Use for Kangaroo Care 150 150 Kevin Mayhood
By: Kevin Mayhood

A parent’s touch reduces agitation, allows infants and toddlers to remain extubated after heart surgery. A small percentage of babies and young children who have undergone congenital cardiac surgery and early tracheal extubation are treated with a calming parent’s touch at Nationwide Children’s Hospital – a strategy that physicians have found works better in some…

How to Integrate Genomics into Clinical Practice
 How to Integrate Genomics into Clinical Practice 150 150 Abbie Miller
By: Abbie Miller

Recommendations from the Clinical Genetics Think Tank outline five key areas of focus for bringing genome and exome sequencing into the clinic. Clinical genome and exome sequencing (CGES) as a diagnostic tool is altering practice for clinical geneticists, genetic counselors and other clinical specialists. The Clinical Genetics Think Tank (CGTT) has identified five areas of…

Great Minds Aren’t Thinking Alike About Asthma Care
 Great Minds Aren’t Thinking Alike About Asthma Care 150 150 Brianne Moore
By: Brianne Moore

A recent audit of the Pediatric Hospital Information System using template matching finds wide variation in care provided to pediatric asthma patients. While asthma is a common and manageable disease, nine people still die from asthma each day. It is well known that asthma is the leading cause of pediatric hospitalization as well as the…

One Dose Probiotic Biofilm Protects Against NEC
 One Dose Probiotic Biofilm Protects Against NEC 150 150 Kevin Mayhood
By: Kevin Mayhood

Probiotic biofilm enables the beneficial bacteria to withstand stomach acid, promote microbial activity and decrease intestinal inflammation. A single dose of a probiotic biofilm grown on microspheres prevented or significantly reduced the severity of necrotizing enterocolitis (NEC) in animal models of the disease, researchers show. This delivery method not only appears to protect against NEC…

Novel Practice Pathway Addresses Problem Behaviors Among Patients With Autism
 Novel Practice Pathway Addresses Problem Behaviors Among Patients With Autism 150 150 Kevin Mayhood
By: Kevin Mayhood

Pediatricians urged to investigate underlying causes. Issues causing children with autism spectrum disorder to be irritable or belligerent can be difficult for parents, teachers and other care providers to uncover. And, wait times to see a specialist may leave a child frustrated, distressed or in physical pain for months. Primary care physicians who see the…

How Can You Optimize Care for Homeless Patients?
 How Can You Optimize Care for Homeless Patients? 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

A recent policy statement from the AAP describes how pediatricians can help improve the health and well-being of homeless children in America. As of 2014, the National Center on Family Homelessness reported that a staggering 2.5 million children are homeless each year in America, a historic high representing one in every 30 children in the country. These…

New Guidelines Better Diagnose Common GI Disorders
 New Guidelines Better Diagnose Common GI Disorders 150 150 Jeb Phillips
By: Jeb Phillips

The new Rome IV criteria offer guidance to common but often misunderstood conditions. Because there are no clear causes of functional gastrointestinal disorders (FGIDs), diagnosis and treatment can be difficult. Some physicians and parents may doubt the disorders exist at all, although pediatric gastroenterologists estimate they affect 30 to 40 percent of children. However, recently…

Minimally-Invasive Technology Proving Itself in Epilepsy Procedures
 Minimally-Invasive Technology Proving Itself in Epilepsy Procedures 150 150 Kevin Mayhood
By: Kevin Mayhood

MRI-guided stereotactic laser ablation may become the option of choice for appropriate patients. MRI-guided stereotactic laser ablation is proving comparable to open surgery in several procedures aimed at controlling epilepsy, researchers report. Importantly, patients’ recovery is considerably easier and shorter than recuperation from traditional surgeries, and while thorough studies are needed, early results indicate fewer…

Use Caution When Prescribing a Gluten-Free Diet
 Use Caution When Prescribing a Gluten-Free Diet 150 150 Kevin Mayhood
By: Kevin Mayhood

A gluten-free diet makes diagnosing underlying conditions difficult and can leave potential, long-term consequences unaddressed. The growing popularity of a gluten-free diet among adults appears to be spilling over to children, with help from the pediatrician’s office. “An increasing number of primary care physicians, who are seeing children with symptoms possibly related to gluten intolerance,…

Oligodendrocytes Induce Motor Neuron Death in ALS
 Oligodendrocytes Induce Motor Neuron Death in ALS 150 150 Jeb Phillips
By: Jeb Phillips

A first-of-its-kind oligodendrocyte in vitro model shows that human cells normally supportive of motor neuron function play an active role in amyotrophic lateral sclerosis pathogenesis – and this discovery may point the way toward therapeutic timing and targets. A number of studies over the last decade have shown that cells which normally support motor neurons,…

Personal, Familial and Social Factors Surrounding Child Suicide
 Personal, Familial and Social Factors Surrounding Child Suicide 150 150 Brianne Moore
By: Brianne Moore

As suicide rates among children climb, researchers publish the first study exclusively focused on the precipitating circumstances of children and young adolescents who die by suicide. According to the Centers for Disease Control and Prevention (CDC), suicide was the 10th leading cause of death for children ages 5 to 11 in 2014. This was the first…

A Painful Reality: Care Providers Tend to Underestimate Pain During Pediatric Burn Dressing Changes
 A Painful Reality: Care Providers Tend to Underestimate Pain During Pediatric Burn Dressing Changes 150 150 Krista Wheeler
By: Krista Wheeler

Researchers call for an updated pain scale. Dressing changes have been identified as one of the major contributors to perceived pain during burn care, and so it is important that pain be assessed accurately. But a new study from the Center for Pediatric Trauma Research in The Research Institute at Nationwide Children’s Hospital suggests that pediatric burn…

What Pediatricians Need to Know About the New Meningococcal B Vaccine
 What Pediatricians Need to Know About the New Meningococcal B Vaccine 150 150 Michael T. Brady, MD
By: Michael T. Brady, MD

Michael T. Brady, MD, infectious diseases specialist at Nationwide Children’s Hospital and primary author of the recent American Academy of Pediatrics position paper on the meningococcal B vaccine, shares what you need to know about this controversial vaccine. Meningococcal serotype B (MenB) causes the majority of invasive meningococcal disease in infants and young children. Though…

Nine Factors for Predicting the Duration of Post-Concussion Symptoms
 Nine Factors for Predicting the Duration of Post-Concussion Symptoms 150 150 Jeb Phillips
By: Jeb Phillips

Concussion recovery is poorly understood, but new research suggests that some factors are predictive of recovery time. Several factors, including continued physical activity following a concussion, worsening symptoms from the time of injury to the time a patient seeks care, and a previous history of headaches, help predict which children are likely to have a…

Finding a Better Way to Diagnose and Treat Iron Deficiency in Young Women
 Finding a Better Way to Diagnose and Treat Iron Deficiency in Young Women 150 150 Brianne Moore
By: Brianne Moore

Iron deficiency without anemia often goes undiagnosed in young women, and when caught, the standard treatment is often associated with poor compliance due to side effects. Dr. Sarah O’Brien’s research is focused on finding a solution. Even in developed countries, iron deficiency continues to be a prevalent nutritional disorder. It is common in women, especially…

Specialized Test Detects Bacterial Infections in Youngest Infants with Fever
 Specialized Test Detects Bacterial Infections in Youngest Infants with Fever 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

The diagnostic test has potential to prevent painful testing, unnecessary antibiotics and hospitalizations for many of the more than 500,000 febrile infants who arrive at hospitals each year. Physicians from Children’s Hospital of Michigan, UC Davis Medical Center and Nationwide Children’s Hospital, in collaboration with 19 other pediatric emergency departments around the country, have established…

Using Whole Exome Sequencing to Find Genetic Cause of Congenital Heart Disease in At-Risk Patients
 Using Whole Exome Sequencing to Find Genetic Cause of Congenital Heart Disease in At-Risk Patients 150 150 Brianne Moore
By: Brianne Moore

Whole exome sequencing has the ability to identify disease-causing mutations, contributing to the development of personalized medicine and bridging a crucial gap between scientific knowledge and clinical application. Congenital heart disease (CHD) is the most common type of birth defect, affecting approximately 40,000 births per year in the United States. While some types of CHD…

Study Finds Genetic Loci Associated With Anxiety and Aggression in Dogs: What Does It Mean for Kids?
 Study Finds Genetic Loci Associated With Anxiety and Aggression in Dogs: What Does It Mean for Kids? 150 150 Carlos E. Alvarez, PhD
By: Carlos E. Alvarez, PhD

Principal investigator Carlos Alvarez, PhD, reports the genome wide mapping of nine fear and aggression traits in dogs and discusses the implications of the findings. Anxiety disorders are the most common type of mental illness in the United States. They are associated with increased risk of schizophrenia, depression, addiction and other psychiatric disorders. While much…

Chromatin’s Role in Cancer Development
 Chromatin’s Role in Cancer Development 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

A new study investigates the role of chromatin containing the histone H3 variant in the centromere region of chromosomes in the development of cancer. Although there are many types of cancer, all cancers have one thing in common: they develop when normal processes in the body break down. Unlike normal cells, cancer cells ignore signals…

Researchers at Nationwide Children’s Hospital Describe New Type of Cancer Therapy
 Researchers at Nationwide Children’s Hospital Describe New Type of Cancer Therapy 150 150 Abbie Miller
By: Abbie Miller

The new chemotherapy is effective against both pediatric and adult cancers, and it allows other chemotherapies to more readily reach their targets. A study conducted at Nationwide Children’s Hospital has found that a new chemotherapy is effective against both pediatric and adult cancers, and that it allows other chemotherapies to more readily reach their targets.…

Considering Peptide Tuning of Natural Killer (NK) Cells
 Considering Peptide Tuning of Natural Killer (NK) Cells 150 150 Abbie Miller
By: Abbie Miller

Researchers combine modeling and functional studies of interactions between MHC-I and NK cells to learn how they operate on a molecular level. Natural killer (NK) cells are cytotoxic lymphocytes — important immune cells of the innate immune system. NK cells are increasingly understood to be significant in the way the body responds to viruses, such…

An Effective Strategy for Disrupting Bacterial Biofilms
 An Effective Strategy for Disrupting Bacterial Biofilms 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

Using monoclonal antibodies to bind to proteins essential to biofilm structure and stability is highly effective against many types of bacteria that cause a variety of human disease. Biofilms are communities of bacteria that adhere to a surface and are nearly impossible to eradicate when they are pathogenic, or disease-causing. Now, a discovery from the laboratories…

When Should Kids With Severe Functional Constipation Have Surgery?
 When Should Kids With Severe Functional Constipation Have Surgery? 150 150 Jeb Phillips
By: Jeb Phillips

A protocol developed by pediatric surgeons and gastroenterologists allows patients to receive specific surgical interventions that will be most beneficial – and allows many patients originally referred for surgery to avoid it altogether. Children with severe functional constipation are most often referred for surgery after failure of medical management. But there’s a problem with this…

Counseling Pediatric Patients on Fertility and Sexual Function
 Counseling Pediatric Patients on Fertility and Sexual Function 150 150 Brianne Moore
By: Brianne Moore

How should we talk to patients and their families about these sensitive subjects? Since 2006, several medical societies have released guidelines for discussing fertility preservation prior to pediatric cancer treatment. According to the American Society for Reproductive Medicine, a “collaborative, multidisciplinary team approach” is vital for informing minors whose chemotherapy may affect their fertility status…

Often-Unreported MRI Finding May Indicate Neurodevelopmental Impairment in Premature Infants
 Often-Unreported MRI Finding May Indicate Neurodevelopmental Impairment in Premature Infants 150 150 Jeb Phillips
By: Jeb Phillips

Moderate-to-severe gyral maturation delay emerged as a significant predictor of overall neurodevelopmental delay in premature infants with extremely low birth weights Magnetic resonance imaging of the brain is increasingly used to predict neurodevelopmental outcomes in premature infants, but the existing systems of scoring those MRIs rely heavily on expert opinion. A recent study led by…

For Infants Born Very Preterm, Transcatheter Device Closure of Patent Ductus Arteriosus is Feasible
 For Infants Born Very Preterm, Transcatheter Device Closure of Patent Ductus Arteriosus is Feasible 150 150 Jeb Phillips
By: Jeb Phillips

Optimal timing of procedures and reduction of adverse events are avenues for future study. Approximately half of babies born at less than 32 weeks of gestational age have persistent patent ductus arteriosus (PDA), a condition associated with higher odds of death and respiratory morbidity. When doctors choose to close the ductus, a percutaneous approach is…

Specialty Pharmacy for Cystic Fibrosis Improves Access to Medication
 Specialty Pharmacy for Cystic Fibrosis Improves Access to Medication 150 150 Abbie Miller
By: Abbie Miller

In a project started to increase the number of patients taking Orkambi®, access and adherence increases for all medications. The Nationwide Children’s Hospital Cystic Fibrosis (CF) Program cares for a large population of patients of all ages with cystic fibrosis.  The program has participated in many recent clinical trials, including one that led to the FDA approval…

A Novel, Promising Strategy for Diagnosing UTIs in Children
 A Novel, Promising Strategy for Diagnosing UTIs in Children 150 150 Tiasha Letostak, PhD
By: Tiasha Letostak, PhD

Antimicrobial peptides may be effective biomarkers for diagnosing urinary tract infections in children. Urinary tract infections (UTIs) are one of the most common infections in children and account for millions of unplanned pediatrician and urgent care visits each year in the United States. Previous research has shown that antimicrobial peptides, referred to as AMPs, are…

Despite Safety Concerns, Nearly 1 in 4 Babies in the NICU Receive Acid Suppressing Medications
 Despite Safety Concerns, Nearly 1 in 4 Babies in the NICU Receive Acid Suppressing Medications 150 150 Jeb Phillips
By: Jeb Phillips

While use is dropping overall as doctors heed warnings, acid suppressing medication originally formulated for older children and adults is still being given to nearly 25 percent of babies in the NICU. Since 2006, several published studies have associated the use of some acid suppression medications in hospitalized high-risk babies with infections, necrotizing enterocolitis and…

First Implantable Hemodynamic Monitoring Device in Single Ventricle Fontan Anatomy
 First Implantable Hemodynamic Monitoring Device in Single Ventricle Fontan Anatomy 150 150 Abbie Miller
By: Abbie Miller

The first IHM in a patient with Fontan anatomy and physiology enables real-time monitoring of central venous and pulmonary artery pressures. While the Fontan procedure has improved the short- and mid-term outcomes for patients born with single ventricle anatomy, long-term complications of Fontan circulation include heart failure. These complications are thought to be secondary to…

Neurologists Urged to Consider MCA When Evaluations Don’t Support Claims
 Neurologists Urged to Consider MCA When Evaluations Don’t Support Claims 150 150 Kevin Mayhood
By: Kevin Mayhood

Up to half of medical child abuse cases include neurological symptoms Medical child abuse (MCA) is highly variable, but neurologists are in a position to help detect up to half of these cases, researchers at Nationwide Children’s Hospital report. Consistent with the authors’ clinical experience, studies estimate that abusive caregivers make up, exaggerate or induce…

Signaling Pathway Changes May Flag CAVD, Offer Target for Therapies
 Signaling Pathway Changes May Flag CAVD, Offer Target for Therapies 150 150 Kevin Mayhood
By: Kevin Mayhood

Loss of TgfB1 from the endothelium leads to a reduction in Sox9 expression and valve calcification. A team of researchers has identified a molecular signaling pathway that, when altered, can contribute to calcific aortic valve disease (CAVD). The finding may provide a method for early diagnosis — many patients don’t learn they have the disease until it’s in the final…

Helping the Sickest Children Navigate the Health Care System
 Helping the Sickest Children Navigate the Health Care System 150 150 Jeb Phillips
By: Jeb Phillips

Care coordination focuses on better outcomes for children with medical complexity. Consider a child with cerebral palsy who needs a feeding tube to eat. She has special equipment for a basic life function. She requires regular visits with a primary care physician and specialists in neurology, orthopedics and gastroenterology. She has frequent acute infections that lead to emergency department visits.…