1. Primary pulmonary hypertension
Pulmonary hypertension - primary and secondary - is more easily recognized and much more commonly diagnosed than in the past. Furthermore, newer therapies are available.
Primary pulmonary hypertension (PPH) is a very serious disease with an unclear etiology. It can be associated with significant morbidity and mortality and is defined as a mean pulmonary artery pressure of greater than 25 mm Hg at rest. Its diagnosis implies that the secondary causes of pulmonary hypertension have been ruled out.
Causes
The exact pathogenesis and pathophysiology of PPH are unclear. The mechanism that seems most widely accepted is vasoconstriction and perhaps an intrinsic imbalance of vasoactive mediators. Factors such as thromboxane, arachidonate metabolites and prostacyclin, as well as other endothelial factors, have been invoked. This area is the target of many of the medical therapies that either currently are available or on the horizon. In addition, coagulation abnormalities may occur, supporting the finding of microthrombi in the pulmonary vascular bed. Whether this is a primary or secondary finding also is not clear.
Prognosis
Morbidity and mortality associated with PPH is significant. Before vasodilator therapy became available, most children died within one to two years of diagnosis. Morbidity and mortality currently is variable depending upon the age, the degree of pulmonary hypertension and the response of vasodilator therapy. Death can occur as a result of both acute and chronic right-heart failure and associated arrhythmias. The morbidity associated with chronic vasodilator therapy and long-term, in-dwelling intravenous catheters, as well as with chronic anti-coagulation therapy also is well known.
Signs and symptoms
The presenting signs and symptoms of PPH also vary depending upon the age of presentation and degree of pulmonary hypertension. Infants and children with significant pulmonary hypertension typically present with symptoms of low cardiac output. This could include poor appetite, irritability, poor growth, nausea, vomiting, tachypnea and tachycardia. If a patent foramen ovale is present, the patient may be desaturated because of a right-to-left intra-cardiac shunt. In patients of any age, syncope could be a presenting symptom. The latter is a particularly ominous sign in patients with PPH. Finally, older patients and adolescents with PPH tend to present with exertional dyspnea and chest pain.
Diagnosis
The work-up for newly diagnosed patients with PPH reflects the differential diagnosis. An echocardiogram is essential in ruling out underlying associated congenital heart disease. Pulmonary function studies, chest radiography and sleep studies are performed in order to rule out either lung disease or airway disease as a cause for pulmonary hypertension. Coagulation studies are performed to rule out hypercoaguable state, liver function studies are performed to rule out liver disease, and collagen-vascular studies are performed to rule collagen-vascular associated pulmonary hypertension. Finally, it is typical to consider a lung perfusion scan to rule out pulmonary thromboembolic disease, although this is relatively rare in children.
Treatment
The treatment for PPH is variable and continually evolving. Most patients with significant PPH are started on coumadin. Prior to the use of vasodilator agents, studies have shown improved survival in the patients that had undergone this therapy. In addition, traditional therapy also has included digoxin. The rationale for this therapy in patients with normal right ventricular function is not entirely clear.
The availability of vasodilator agents has been a major therapeutic advance for this population of patients. It is typical that newly-diagnosed patients undergo an initial cardiac catheterization study. The purpose of the study is to document baseline hemodynamics and to test the acute response to vasodilator agents such as inhaled nitric oxide and intravenous prostacyclin. A favorable acute response is defined as a 25 percent reduction in pulmonary artery pressure and increase in cardiac output. A favorable acute response is associated with a favorable prognosis.
However, many patients do not demonstrate a favorable acute response, especially if they present at an older age. In this group of patients there is reasonable evidence to suggest that chronic vasodilator therapy may be reasonable and that chronic remodeling of the pulmonary circuit may still be possible. It has been Children's Hospital of Wisconsin's approach, therefore, to initiate therapy with continuous intravenous prostacyclin therapy in all patients with PPH who have significant pulmonary hypertension, whether or not they are acute responders. It also has been our approach in the non-responder group to list them for lung transplantation at the time of diagnosis.
The future availability of newer and different forms of vasodilator agents may alter the choice of initial therapy. Following is a brief review of vasodilator agents currently available or perhaps available in the near future:
Vasodilator agents
Prostacyclin analogues
- Flolan-intravenous prostacyclin therapy – This form of therapy has been used for several years and has been discussed briefly above. It is a potent vasodilator and inhibitor of platelet aggregation. It is not specific to the pulmonary circulation and therefore it has moderate systemic effects. Tachyphylaxis also is present, requiring frequent dose increases. It requires central venous access and continuous intravenous therapy.
- Treprostinil (remodulin, UT-15) – This has the same effects and side effects as flolan. However, this is administered subcutaneously via a constant infusion. It may cause infusion site pain and irritation. Use of this agent avoids central intravenous line and attendant potential complications. This form just recently has been approved by the Food and Drug Administration (FDA).
- Inhaled prostacyclin therapy (Iloprost) – Not yet available for general use. FDA release planned soon.
- Oral prostacyclin therapy (Beraprost) – Not yet available for general use, but also to be released soon.
Endothelin receptor antagonists
Competitively binds to endothelin-1 receptors causing reduction in pulmonary artery pressure and pulmonary vascular resistance by inhibiting vessel constriction.
- Bosentan (Tracleer) - An oral agent that has been studied in adult patients with PPH. The studies have shown an increase in exercise ability and a decrease in the rate of clinical worsening. It is contraindicated in pregnancy and has been associated with elevation in liver transaminases in 10 percent of patients. It can be used in association with prostacyclin agents. There are ongoing studies in children.
Inhaled nitric oxide
Home therapy with inhaled nitric oxide currently is under study. FDA approval is pending and likely will occur sometime in the near future.
Sildenafil
Sildenafil is a nitric oxide analog and a very potent vasodilator. It does not have specific effects on the pulmonary vasculature and it therefore has systemic side effects. It has been used in Europe with anecdotal benefits in children and adults with both primary and secondary pulmonary hypertension. It currently is being used in an off-label fashion in the United States. Two multi-institutional, double-blind controlled studies are being planned for the use of sildenafil in pediatric primary hypertension. The first study involves the use of oral sildenafil in pediatric primary hypertension. The second study involves the use of intravenous sildenafil in pulmonary hypertension immediately following the surgical repair of congenital heart defects. Children's Hospital will be participating in both studies.
The future for patients with PPH
The long-term prognosis for patients with PPH is unclear but constantly is improving. Newer vasodilator agents and modes of administration continue to evolve and improve quality of life. For patients with severe and symptomatic pulmonary hypertension unresponsive to medical therapy, lung transplantation continues to be an effective, life-saving therapy.
For more information:
Herma Heart Center (Cardiology):
(414) 266-2380
To make an appointment:
Central Scheduling:
(414) 607-5280 or (877) 607-5280
2. Common pediatric issue: Type 1 Diabetes Mellitus
Type 1 Diabetes Mellitus (DM) is a common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature, formerly known as insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes. This metabolic syndrome is caused by marked hypoinsulinemia or insulinopenia with dependence on exogenous insulin to prevent development of diabetic ketoacidosis (DKA), an acute life-threatening complication of type 1 DM. The natural history of this disease indicates that there are pre-ketotic, non-insulin-dependent phases both before and after the initial diagnosis. The onset occurs predominantly in childhood, with median 7 to 15 years of age, but it may come at any age. Type 1 DM is characterized by autoimmune destruction of pancreatic islet-cells. Both genetic susceptibility and environmental factors contribute to the pathogenesis of type 1 DM. Susceptibility to Type 1 DM is genetically controlled by alleles of the major histocompatability complex (MHC) class-II genes expressing human leukocyte antigens (HLAs). It also is associated with autoantibodies to islet cell cytoplasm (ICA), insulin (IAA), antibodies to glutamic acid decarboxylase (GAD65), and ICA512 (IA2). In addition, Type 1 DM is associated with other autoimmune diseases such as Hashimoto's thyroiditis, celiac disease and Addison. The incidence of Type 1 DM is 14.9 to 20 per 100,000 in the U.S. population per year, but it rapidly is increasing in specific regions of the world and shows a trend toward earlier onset. It is predicted that the overall incidence of type 1 DM will be about 40 percent higher in 2010 than in 1997.
Diagnosis
The diagnosis of Type 1 DM usually is straightforward if considered in the differential diagnosis. Though most symptoms are nonspecific, the signal clue is often an inappropriate polyuria in any child with dehydration, poor weight gain or "the flu." Hyperglycemia, glucosuria and ketonuria can be checked quickly. A random blood glucose (BG) level above 200 mg/dl with typical symptoms is diagnostic with or without ketonuria. In the obese child, Type 2 DM, formerly known as non-insulin-dependent diabetes mellitus, must be considered. Once hyperglycemia is confirmed, the presence or absence of DKA should be ruled out, especially if ketonuria is found, even if signs of dehydration are minimal. Serum bicarbonate (total CO2), electrolytes and venous pH can help determine if an apparently asymptomatic child is in early stages of DKA. A baseline HbA1c allows an estimate of the duration of hyperglycemia and provides an initial value by which to compare the effectiveness of subsequent therapy.
In the non-obese child, testing for autoimmunity to beta cells is not necessary. Other autoimmunities associated with Type 1 DM should be screened, including celiac disease (tissue transglutaminase IgA and total IgA) and thyroiditis (free T4, TSH, anti-thyroid peroxidase and anti-thyroglobulin antibodies).
Treatment
Therapy is tailored to the degree of insulinopenia at presentation. Most children with new diabetes (60 to 80 percent) will have mild to moderate symptoms, minimal dehydration with no history of emesis and will not have progressed to DKA. A minority of children will present with some degree of DKA. Therapy for DKA is instituted by using the Children's Hospital of Wisconsin DKA protocol. Once DKA has resolved in the newly diagnosed child, therapy is transitioned to that described for children with without DKA onset (see below). Children with previously diagnosed diabetes who develop DKA usually are transitioned to their previous insulin regimen. The Children's Hospital Diabetes Center is one of the few programs in the country that initiates insulin treatment in the outpatient clinic in medically stable patients.
New onset type 1 DM without DKA
Excellent diabetes control involves a balance between tight glucose control and hypoglycemia, elimination of polyuria and nocturia, to prevent DKA; and maintenance of normal growth and development with minimal effect on lifestyle. Therapy encompasses initiation and adjustment of insulin, extensive education of the child and caretakers, and re-establishing the routine of life. Ideally, therapy can begin in the outpatient setting, with complete team staffing by a pediatric endocrinologist, experienced diabetes nursing clinicians and educators, dietitians and social workers.
Insulin
The total daily dose of insulin requirement, expressed as unit (U) per kilogram (kg) body weight is estimated at:
In patients with Type 1 DM, treatment with multiple daily insulin (MDI) injections involves the use of carbohydrate counting and pre-meal insulin per grams of carbohydrate, which affords greater flexibility in choosing foods, portion size and timing of the meals as well as physical activity.
Daily insulin is divided between bolus or fast-acting (60 to 70 percent of total) and basal or long-acting (30 to 40 percent) doses. New fast-acting insulin analogs, lispro or Humalog® and aspart or Novolog®, are absorbed much more quickly than conventional regular (R) insulin and provide discrete pulses with little if any overlap and short tail effect. This allows better control of post-meal glucose rise and reduces between meal or nighttime hypoglycemia. The new long-acting analog glargine (G) or Lantus® usually is dosed once daily at bedtime and creates a much flatter 24-hour profile. This makes it much simpler to predict the combined effect of a rapid bolus (lispro or aspart) on top of the basal insulin glargine; a more physiologic pattern of insulin effect results. A simple sliding-scale dosing schedule is begun based upon the pre-meal BG level. As soon as the family is taught to calculate the carbohydrate content of meals, bolus insulin can be more accurately dosed by both the carbohydrate content of the meal as well as ambient glucose. Frequent BG monitoring and insulin adjustment are necessary in the first weeks as the child returns to routine activities and adapts to a new nutritional schedule, and as the total daily insulin requirements are determined.
Education
The Children's Hospital Diabetes Center provides a comprehensive outpatient education program. The program teaches initial basic (survival) skills (BG testing, insulin administration, treatment of hypoglycemia, meal planning) during the first week of diagnosis and advanced education (flexible meal planning, sick day management, insulin dosing, and exercise) over the proceeding four months. Every patient is case-managed by a nurse clinician/educator during the first six months of diagnosis in order to help families with diabetes self-care and educational objectives, the honeymoon period (variable insulin requirement) and coping with diabetes-related psychosocial issues. Close contact between the diabetes team and family must be assured for optimal outcome.
For more information:
Diabetes Center:
(414) 266-6750
To make an appointment
Central Scheduling:
(414) 607-5280 or (877) 607-5280
3. Pediatric heart surgery collaboration forged by Children's Hospital of Wisconsin, Medical College of Wisconsin and Loyola University Health System
Pediatric heart surgeons from Children's Hospital of Wisconsin and the Medical College of Wisconsin will begin performing surgery at the Ronald McDonald Children's Hospital of Loyola University Medical Center in Maywood, Ill., under a new agreement announced by the three institutions.
Under the agreement, three Milwaukee-based pediatric cardiothoracic surgeons will travel to Loyola to see patients, conduct a pediatric heart surgery clinic and perform surgeries as needed at Loyola's specially designed children's hospital. They also will serve as adjunct professors at the Loyola University Chicago Stritch School of Medicine. They began performing procedures at Loyola in February.
Under a similar collaboration that has existed since July 2000, Children's Hospital and Medical College pediatric heart surgeons have been performing surgeries in Marshfield under an agreement with Marshfield Clinic and St. Joseph Hospital.
"The collaboration allows us to build our nationally acclaimed heart program in an innovative way," said Anthony L. Barbato, MD, president and CEO, Loyola Health System. "We are excited about offering these surgeons with their depth of experience to our pediatric patients."
The surgeons who now are performing pediatric cardiothoracic surgery at Loyola are:
James S. Tweddell, MD, medical director of Cardiothoracic Surgery and director of Cardiothoracic Transplantation at Children's Hospital and associate professor of surgery (pediatric cardiothoracic) at the Medical College. He will serve as medical director of Pediatric Cardiovascular Surgery at Loyola. Tweddell is a member of Children's Specialty Group.
Robert D. Jaquiss, MD, cardiothoracic surgeon at Children's Hospital and assistant professor of Surgery (Pediatric Cardiothoracic) at the Medical College. Jaquiss is a member of Children's Specialty Group.
S. Bert Litwin, MD, cardiothoracic surgeon and director emeritus at Children's Hospital and clinical professor of Surgery (Pediatric Cardiothoracic) at the Medical College.
"The program at Children's Hospital of Wisconsin is one of the largest in the country, performing more than 600 procedures per year," said Jon Vice, president and CEO of Children's Hospital. "We are in the top 10 in volume in both pediatric and neonatal open heart admissions nationally, and we have the best published survival statistics in the world for the Norwood (a procedure to correct complex newborn heart defects)."
"This collaboration between two academic medical centers serves as a national model," said T. Michael Bolger, JD, president and CEO of the Medical College. "By sharing expertise in a highly specialized field of surgery, we are guaranteeing patients access to a team that conducts high volumes of surgery while also maintaining a commitment to research and medical education."
4. New Children's Specialty Group members
Asthma/Allergy
Marshall H. Benner, MD, allergy/asthma/immunology specialist at Children's Hospital of Wisconsin, joined the department of Pediatrics (Allergy) at the Medical College of Wisconsin in January 2003 as an assistant professor. Benner earned his medical degree from the University of Wisconsin, Madison and completed his allergy fellowship at University of Wisconsin Hospitals, Madison. He is board certified in Internal Medicine and Allergy and Immunology. Prior to joining Children's Specialty Group, Benner was in private practice for 32 years.
Child Development
Robert Russell, PhD, child development specialist at Children's Hospital of Wisconsin, became a professor in the department of Pediatrics (Child Development) at the Medical College of Wisconsin in January. Russell received a master's degree in linguistics at the University of North Carolina, Chapel Hill, and a master's degree in philosophical psychology at Duquesne University, Pittsburgh. He earned a doctorate in clinical psychology at Clark University, Worcester, Mass., and completed an internship at Harvard Medical School. His areas of emphasis include developmental psychopathology, discourse analysis, learning/language disorders, treatment process and outcome evaluation, quantitative and qualitative research methodology and doctor-patient communication.
Neonatology
Gary A. Cohen, MD, neonatologist at Children's Hospital of Wisconsin, became an assistant professor in the department of Pediatrics (Neonatology) at the Medical College in February 2003. Cohen earned his medical degree from the Medical College and completed an internship and residency at Children's Hospital. He is board certified in Pediatrics. Prior to joining Children's Specialty Group, Cohen was a pediatrician in the Milwaukee community for 20 years.
Neurology
Michael J. Schwabe, MD, neurologist at Children's Hospital of Wisconsin, became an assistant professor in the department of Neurology at the Medical College of Wisconsin in January. Schwabe earned his medical degree from the Medical College and completed an EEG/Epilepsy fellowship at the University of Texas-Houston Health Science Center. He is board certified in Neurology and Psychiatry with special qualification in child Neurology. His areas of emphasis include pediatric epilepsy and the comprehensive treatment of seizures and epilepsy in children.
5. Unique concept forms comprehensive, cohesive heart center
In February, the Heart Center at Children's Hospital of Wisconsin was renamed to reflect a new, coordinated concept.
A recent Herma Heart Center endowment establishes a comprehensive program for advancing the care of children with cardiac disease to a level otherwise not achievable without the integrated center concept. The endowment also includes support for cardiac research, education, capital equipment and facilities.
In this new program model of an integrated center, the Cardiology and Cardiothoracic Surgery departments have been formally combined to provide seamless care for children with congenital heart disease and their families. This allows Children's Hospital to capitalize on its strengths, providing premier care for children leading to clinical outcomes that rank the hospital as one of the world leaders in caring for children with heart disease.
6. Research News
"Medical Homes" for children with special needs
Children's Hospital of Wisconsin recently became involved in a project with the Wisconsin Children with Special Health Care Needs (CSHCN) program to participate in a national collaborative for establishing "Medical Homes" for children with special needs. Holly Colby, APN, Ambulatory Services manager for Genetics and Birth Defects at Children's Hospital of Wisconsin, is the local lead. The first year will involve three primary care practices. In subsequent years, education and support will be provided to more practices to improve their ability to manage these children. Children's Hospital is the lead non-government agency helping coordinate the program. John Gordon, MD, medical director of Intermediate Care and Special Needs at Children's Hospital, associate professor of Pediatrics (Critical Care) at the Medical College, is medical director for the project.
Physiology paper accepted
John Gordon, MD, medical director of Intermediate Care and Special Needs at Children's Hospital of Wisconsin; associate professor of Pediatrics (Critical Care) at the Medical College, along with two critical care fellows and three other collaborators, wrote a paper, "What leads to different mediators of alkalosis-induced vasodilation in isolated and in-situ pulmonary vessels?" recently accepted by the American Journal of Physiology.
Hemifacial Microsomia study continues
Arlen Denny, MD, FACS, FAAP, Plastic and Craniofacial Surgery, is co-investigator on a study that began in 1998, "Cases control study of Hemifacial Microsomia."
7. Physician notes
Endowed Chair in Critical Care Medicine established
Dennis and Jean Bauman of Mequon, Wis., made a $1 million gift to establish an endowed chair in Critical Care Medicine. The chair, held by Tom Rice, MD, medical director of Critical Care and Lung Transplant at Children's Hospital of Wisconsin and professor of Pediatrics (Critical Care) at the Medical College of Wisconsin, supports research and patient care activities.
Off-site asthma and allergy clinic opens to serve Milwaukee's north shore
Milwaukee area asthma and allergy patients now have a choice of where to receive their care – Children's Hospital of Wisconsin in Wauwatosa or the new Children's Hospital of Wisconsin Clinics–North Shore in Brown Deer, which opened March 17.
Both clinics are:
- Full-service, offering allergy testing and shots (immunotherapy).
- Staffed by asthma/allergy physicians who specialize in treating children and adults through their affiliations with Children's Hospital and the Medical College of Wisconsin. They include: Marshall Benner, MD; Jordan Fink, MD; Michael Levy, MD; and Morton Soifer, MD.
- Designed to meet the needs of the whole family.
"We noticed a large population of our patients were commuting from the north shore area to receive care at our main clinic in Wauwatosa," said Kevin Kelly, MD, medical director of Allergy at Children's Hospital and a professor of Pediatrics and Medicine at the Medical College. "We decided to bring the physicians to the patients, making it more convenient for them to receive care."
Located off of Green Bay Road just north of Brown Deer Road, the north shore clinic is easy to find and has ample parking.
"We anticipate this new clinic will be well received," said Lee Anne Eddy, director of Ambulatory Services at Children's Hospital. "And we hope to eventually expand this clinic to include other health care specialties."
Office hours at the new clinic are 8:30 a.m. to 5 p.m. Monday through Thursday. To make an appointment, call Central Scheduling at (414) 607-5280 or toll free at (877) 607-5280.
New Pediatric GI Clinic available in Green Bay
Pediatric gastroenterology specialty care now is available in a GI Clinic located in the Medical Arts Building at Bellin Hospital, Green Bay, Wis.
Colin Rudolph, MD, PhD, medical director of Pediatric Gastroenterology and Nutrition at Children's Hospital of Wisconsin, and a professor of Pediatrics (Gastroenterology) at the Medical College of Wisconsin, is seeing patients once a month in Green Bay. He has a national reputation in the treatment of feeding disorders and function motility disorders of the bowel.
In addition to the new GI Clinic in Green Bay, patients can be seen at Children's Hospital of Wisconsin, located near Milwaukee, and at Children's Hospital of Wisconsin Clinics–Fox Valley, located in Neenah. Rudolph leads a department of eight board certified gastroenterologists at Children's Hospital of Wisconsin. GI programs focus on gastroesophageal reflux disease, constipation, inflammatory bowel disease, liver disease, motility and feeding disorders and other gastrointestinal disorders.
Pediatric Gastroenterology Center at Children's Hospital
Ellen Blank, MD
Feeding disorders and general pediatric gastroenterology
Issam Halabi, MD
General pediatric gastroenterology
Subra Kugathasan, MD
Inflammatory bowel disease
Alfonso Martinez, MD
Nutrition and general pediatric gastroenterology
Colin Rudolph, MD, PhD
Medical Director
Feeding disorders and motility disorders of bowel
Michael Stephens, MD
Inflammatory bowel disease and general pediatric gastroenterology
Gregor Telega, MD
Liver disease/transplant and general pediatric gastroenterology
Steven Werlin, MD
Pancreatic disease, motility and general pediatric gastroenterology
Joan Arvedson, PhD
Coordinator, feeding and swallowing services
Margaret Friedhoff, RN, MSN, CPNP
Constipation Clinic
Margo Kinservik, RN, CPNP
Constipation Clinic
Carol Roberson, RN, MSN, CPNP
Constipation Clinic
Appointments
To schedule an appointment for your patients in Green Bay, call (920) 445-7272 (please indicate pediatric GI clinic).
To schedule an appointment for your patients in Milwaukee or Neenah, call (877) 607-5280 or (414) 607-5280.
For a pediatric specialist consultation, referring physicians may call (800) 810-2110.
8. Common pediatric issue: Childhood appendicitis
Appendicitis remains the most common surgical emergency of childhood, and a major surgical reason for emergent hospitalization among children 1 to 14 years of age. Advances in the diagnosis and treatment of appendicitis have significantly reduced the morbidity and mortality of appendicitis over the past 50 years.
Appendiceal inflammation is generally secondary to obstruction of the appendiceal lumen, leading to venous congestion and an acute inflammatory response. Left untreated, acute inflammation of the appendiceal wall may progress to transmural ischemia, leading to gangrenous appendicitis. Full-thickness necrosis of the appendiceal wall with bacterial contamination of the peritoneal cavity is referred to as perforated appendicitis. As expected, infectious complication rates rise significantly with gangrenous and perforated appendicitis.
In an ideal clinical situation, the diagnosis and treatment of appendicitis is performed prior to perforation. However, children represent an extremely difficult group to achieve this goal. Approximately 39 percent of all children in the U.S. will present with perforated appendicitis. In children under 4 years of age, nearly two-thirds will have perforated appendicitis. At least half of misdiagnosed children will have minimal or no pain on initial physician evaluation and these children will more frequently have perforated appendicitis with abscess.
Approximately 30 percent of adolescent females are initially misdiagnosed with conditions other than appendicitis [1]. While diagnostic accuracy increases with increased duration of symptoms, rates of perforation also increase.
Common presenting symptoms of appendicitis in children include abdominal pain, nausea or vomiting and anorexia. It is interesting to note that duration of symptoms is variable, and fever is present in less than 20 percent. The most reliable physical finding is reproducible right lower quadrant tenderness to percussion or palpation. The diagnostic accuracy rate appears to be related to the experience of the examining surgeon and the index of suspicion for appendicitis. In a randomized, double-blind, placebo-controlled clinical trial, Children's Hospital of Wisconsin recently demonstrated that the judicious use of morphine analgesia in the emergency department to relieve abdominal pain does not appear to change diagnostic accuracy or interfere with surgical decision-making [2]. In clinically equivocal cases, helical CT scan imaging of the lower abdomen and pelvis has become a useful diagnostic adjunct, particularly in very young children or adolescent females suspected of having appendicitis. The sensitivity and specificity of computed tomography for appendicitis is approximately 97 percent [3]. While perforation rates are affected by multiple factors, an interesting question is whether liberal use of CT imaging in children with suspected appendicitis will lead to earlier diagnosis and subsequent decrease in perforation.
Following diagnosis, children with appendicitis will be given intravenous fluid and broad-spectrum antibiotics. Appendectomy generally is performed once the child is physiologically stable. Laparoscopic appendectomy is an effective therapeutic option for uncomplicated appendicitis. This approach requires three small incisions compared to a single incision, with longer operative times and decreased post-operative analgesic requirements [4]. Whether open or laparoscopic, a normal appendix will be found and removed in approximately seven percent of cases, and an operative search for an alt
For more information:
Surgery Clinic:
(414) 266-6557
To make an appointment
Central Scheduling:
(414) 607-5280 or (877) 607-5280
Selected References
1. Rothrock SG, Skeoch G, Rush JJ, et al. Annals of Emergency Medicine 20: 45-50, 1991.
2. Kim MK, Strait RT, Sato TT, et al. Academic Emergency Medicine 9: 281-287, 2002.
3. Pena BM, Taylor GA, Lund DP, et al. Pediatrics 104: 440-6, 1999.
4. Lintula H, Kokki H, Vanamo K. British Journal of Surgery 88: 510-14, 2001.
9. Unique program addresses fetal abnormalities
The Fetal Concerns Program, a cooperative effort between the Froedtert & Medical College Birth Center and Children's Hospital of Wisconsin, provides a complete range of care for women whose pregnancies are complicated by concerns of fetal abnormalities. It is the only program of its type in Wisconsin and is unique across the country. The program has attracted patients throughout Wisconsin, northern Illinois and other states, including Colorado and New Mexico.
The multidisciplinary program offers health services, as well as education and counseling. The goal is to maximize the probability of a healthy pregnancy. Since the program began in September 2001, it has helped more than 250 families.
Most of the services within the program have been available for several years, but this program provides a central contact person who can help families work through the many options available. Co-directors of the program are Steven Leuthner, MD, neonatologist at Children's Hospital of Wisconsin, and Thomas Wigton, MD, perinatologist at Froedtert Hospital. Leuthner also is a assistant professor of of Pediatrics (Neonatal-Perinatal Medicine) at the Medical College of Wisconsin. Wigton is an associate professor of Obstetrics and Gynecology at the Medical College of Wisconsin.
In the Fetal Concerns Program, all care is coordinated through a specially-trained nurse coordinator. Program Coordinator Emilie Lamberg Jones, RN, BSW, arranges services and provides ongoing counseling and information, both prior to and immediately after the birth. Having a "familiar face" to turn to during this potentially traumatic time is intended to ease the process of adjustment for the mother and the entire family. Lamberg Jones works closely with both the Froedtert & Medical College Department of Obstetrics and Gynecology and the Children's Hospital Department of Neonatology. In her role as an advocate for the family, Lamberg Jones helps coordinate the other specialists at Children's Hospital, including: Genetics, General Surgery, Cardiology and Cardiothoracic Surgery, Nephrology, Urology, Neurology, Neurosurgery, Orthopedic Surgery, Cleft Lip and Palate and the Infant Death Center of Wisconsin. Other areas involved include: Palliative Care, Pastoral Care, Child Life, Poison Center and the Birth Defects Research Center.
Early diagnosis is beneficial in reducing stress on a family dealing with an abnormal pregnancy. Anxiety is reduced by giving families time to grieve the loss of a normal pregnancy. With early diagnosis, the Fetal Concerns program
Fetal Concerns Program
Services available:
- Education on prevention of birth defects.
- Fetal diagnosis of birth defects.
- Prenatal counseling regarding the specific diagnosis with the neonatologist, the maternal fetal specialist and the pediatric and surgical specialists.
- Obstetrical management and delivery.
- Neonatal management of the infant.
- Linking families to support services.
For more information:
Call Stephen Leuthner, MD, neonatologist at Children's Hospital of Wisconsin, assistant professor of Pediatrics (Neonatal-Perinatal Medicine) at the Medical College of Wisconsin, member of Children's Specialty Group and co-director of the Feta
10. Community pediatrician involved in hospital and legislative leadership
While many pediatricians would find managing a busy pediatric practice on the east side of Milwaukee a challenge by itself, Catherine Slota-Varma, MD, also finds time to assist students with rotations through her clinic, serve on statewide legislative committees dealing with health care issues and participate on the medical leadership team at Children's Hospital of Wisconsin.
Slota-Varma earned her medical degree from Loyola-Stritch University in Maywood, Ill., and completed residencies at Loyola University of Chicago and at the Medical College of Wisconsin, Milwaukee. Her interests include adolescent medicine, children with asthma and other chronic needs.
When she completed her residency in 1979, Children's Hospital was located in downtown Milwaukee. It now is located in Wauwatosa, on the campus of the Milwaukee Regional Medical Center.
"In the past two decades, there has been unbelievable growth and improvement at Children's Hospital," Slota-Varma said. "There now are many pediatric specialists in key areas including critical care, anesthesia, emergency medicine and cardiac surgery. I am so proud to be part of the organization and its amazing growth."
Slota-Varma began her hospital medical staff leadership roles as a member of the Children's Hospital Credentialing Committee, of which she later became chairperson. "Our committee reworked how our physicians became credentialed. It had gotten so complicated and we needed to make sure we were within all legal parameters," Slota-Varma said. She served as vice chief of staff from 1993 to 1995 and chief of the Medical/Dental Staff from 1995 through 1999.
"I enjoy leadership roles where I can make a difference," said Slota-Varma. "Children's Hospital is a place where there is positive discussion and important decisions that need to be made. It is exciting to be a part of it all. I certainly found it very rewarding to hold an office with the hospital."
Slota-Varma's leadership reaches to the legislative arena as well. She is a past president of the Milwaukee County Medical Society and serves as a member of Wisconsin Medical Society board. Recently, she served on a legislative committee dealing with the issue of mental health parity.
"It was an exciting opportunity to participate in a half dozen meetings in Madison, and develop and submit a recommendation to the full legislative council. I was ecstatic to learn that the legislative council just approved our mental health parity recommendation – it now has a good chance for approval in the legislature."
Slota-Varma has shared ideas about Wisconsin's excellent medical malpractice laws with leaders from other states, and recently she completed work with a health care reform committee of the Wisconsin Medical Society, discussing quality, cost and universal coverage. "There is so much happening in health care in the state," said Slota-Varma. Other areas of legislative interest include bike helmet and primary seat-belt laws.
She and her colleagues in their independent pediatric practice on the east side regularly host students to do part of their pediatric rotations. They take the most students of any pediatric practice in the area. The six-physician pediatric clinic (five are women) on the east side shows aspiring physicians how a busy practice operates. "We believe teaching is so important – so while it may take more time and energy, we love to do it," Slota-Varma said. "It's rewarding and we enjoy writing letters of recommendation for students who rotate through our practice."
The east side location provides an urban practice with suburban and central city mix, and diverse populations are served. Slota-Varma and her colleagues care for newborns at St. Mary's Hospital and Columbia Hospital locations and admit to Children's Hospital.
Despite her busy professional life, Slota-Varma does find time for herself and her husband. They enjoy cooking and traveling together. In addition, Slota-Varma started weight and strength training about a year ago and enjoys hiking and pleasure reading.
"When it comes down to it, I want to be involved in 'the big picture.' I want to help the profession," Slota-Varma said. "And I have Jon Vice, president and CEO of Children's Hospital, and a current and former medical staff leader, Dr. Bob Miller and Dr. Jack Alstadt, to thank for helping me and others to become better leaders at Children's Hospital and in the community."
CME Program schedule
CME programs are available in Milwaukee, the Fox Valley (Children's Hospital of Wisconsin-Fox Valley in Neenah and Appleton Medical Center in Appleton), Kenosha (Kenosha Medical Center Campus) and Waukegan, Ill. (Provena Saint Therese Medical Center). Check the Children's Health System Web site for the schedule of programs in your area. Click on "calendar" on the home page.
11. Children's Hospital growth continues
Children's Hospital of Wisconsin continues to see an increasing number of children who require state-of-the-art medical care. More than 20,000 children were admitted to Children's Hospital last year, up nearly four percent from the year before. On average, there were 185 patients in the 222-bed hospital each day.
Growth also occurred in emergency department visits and outpatient specialty and urgent care clinic visits. The emergency department saw nearly 45,000 patients in 2002, an average of 123 per day. Last year, outpatient specialty and urgent care visits topped more than 230,000.
Children's Hospital of Wisconsin transport services set a record in 2002, transporting 1,130 newborns, infants and children by ambulance, helicopter and airplane.
Children's Hospital of Wisconsin-Kenosha, a 31-bed hospital located on the Kenosha Medical Center Campus, had 888 admissions last year. Another 637 pediatric patients were admitted to Children's Hospital of Wisconsin-Fox Valley – in the 22-bed Pediatric Unit and the 24-bed Neonatal Intensive Care Unit.
In comparison to 38 hospitals that are members of the Child Health Corporation of America (CHCA), Children's Hospital of Wisconsin is in the top three in terms of inpatient volume and in the top 15 for outpatient volume.
Service enhancements in 2002
Neonatal Intensive Care Unit (NICU): An expanded 41-bed NICU opened mid-year at Children's Hospital. To provide privacy and a quiet environment for patients and families, the bed spaces of the NICU are set up in pods. Each pod contains six separate infant rooms with state-of-the-art equipment. Each room has rocker-recliners, private lockers, refrigerators and sinks and can be adjusted for the unique needs of each baby. In addition, the new NICU has twin and triplet rooms, isolation rooms and an in-unit pharmacy. Consultation and conference rooms are available for meetings or education, and the bereavement room provides a secluded place for undisturbed solitude. On the floor directly above the NICU is the family area. This hotel-like area was designed in conjunction with the Ronald McDonald House staff for NICU and PICU families in crisis who cannot leave the hospital. Amenities include seven parent resting rooms, two full baths, a self-service kitchen, lounge, dining area and laundry facilities. Additional improvements include a new in-unit operation and procedure room, as well as two rooms for parents to provide independent care prior to discharge.
Children's Hospital Poison Center: In 2002, the Children's Hospital Poison Center became the only program in the state answering emergency calls and offering public education about poison hazards. It has the state's only trained medical toxicologist. One of three medical toxicologists are available 24 hours a day, 7 days a week, for immediate consultation with the Poison Center's nursing staff and for physicians and health care providers across Wisconsin. The center fielded more than 53,000 calls last year, resolving most of them over the phone without an emergency room visit. The number for the Children's Hospital Poison Center is: (800) 222-1222.
Trauma, illness and death in a child's life
Robin Goodman, PhD, ART-BC, a practicing clinical psychologist and art therapist in New York, is the featured speaker at presentations scheduled for Tuesday, April 29 at noon at Hawthorn Suites in Pleasant Prairie (Kenosha) and at 5:30 p.m. in the Children's Hospital of Wisconsin auditorium. This is a joint program between Children's Hospital and Rogers Memorial Hospital. Approximately two years ago, Children's Hospital, the Medical College of Wisconsin and Rogers Memorial Hospital announced a collaboration to care for children with mental, emotional and behavioral issues.
Goodman serves as an associate professor of Psychiatry, director of Bereavement Programs and AboutOurKids.org, a child mental health and parenting Web site hosted by the New York University Child Study Center. She was a guest on NBCs Today Show and ABCs Good Morning America, discussing mental health issues that affect children and families. She has undertaken a major role in the work the Child Study Center is doing with children in the New York area who lost a parent in the 9/11 disaster. She is a co-author of the recently released book, The Day Our World Changed: Children's Art of 9/11. A registered and board certified art therapist, Goodman is a past president of the American Art Therapy Association.
At the April 29 presentations, remarks also will be provided by Bruce Himelstein, MD, program director, Palliative Care, Children's Hospital; and Peter Lake, MD, medical director, Child and Adolescent Services, Rogers Memorial Hospital. |
