April 1, 2014

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On February 23, 2012, the Fetal Center announced the birth of baby Charlotte, the first baby at Texas Children’s to receive in-utero surgery to treat spina bifida. Now, a little more than two years later, the center is celebrating another milestone with 20 cases completed.

After years of treating spina bifida by a neurosurgical closure of the spine defect during the first days of life, research breakthroughs prompted the Texas Children’s Fetal Center team to begin performing in-utero surgery on patients with a prenatal diagnosis of spina bifida.

Myelomeningocele, also known as spina bifida or open neural tube defect (NTD), is a developmental defect in which the spine is improperly formed and the spinal cord is open to and fused with the skin; it is usually associated with hydrocephalus, which requires surgical treatment to drain the fluid via a shunt. Myelomeningocele occurs in 3.4 out of every 10,000 live births in the U.S. and is the most common permanently disabling birth defect for which there is no known cure.

Advancements in fetal imaging and early prenatal diagnosis allow the team to gain access to a fetus while still inside a mother’s womb. Texas Children’s Fetal Center has developed extensive screening and diagnostic algorithms for pregnancies with fetal spina bifida. These algorithms determine which patients are appropriate candidates for the in-utero surgery.

The surgery is a huge, multi-disciplinary effort, bringing together a team of specialized experts, who all play a vital role in the medical treatment of both mom and baby. The team includes maternal-fetal specialists, led by Dr. Michael Belfort, fetal surgeons, led by Dr. Darrell Cass and Dr. Oluyinka Olutoye, and a neurosurgery team, led by Dr. William Whitehead. Once the fetus is exposed, Dr. Whitehead and his team surgically close the spinal defect before fetal surgeons return the baby to the womb. This procedure reduces the risk of hydrocephalus and may improve motor function in select patients.

A NICHD-funded study entitled the Management of Myelomeningocele Study (MOMS) published in the New England Journal of Medicine demonstrated a significant decrease in the risk of hydrocephalus for select patients undergoing fetal closure of the spine, as well as possible improvement in lower extremity function, compared to patients who underwent standard closure after birth. The MOMS trial is the second fetal intervention that has proved beneficial through a multi-center randomized clinical trial. The first was the Euro FETUS trial for laser ablation in the treatment of twin-to-twin transfusion syndrome (TTTS).

“Breakthrough studies like the MOMS trial are exciting and reaffirm our commitment to advancing fetal medicine and giving babies with complications and anomalies the healthiest possible start to life,” said Dr. Darrell Cass, co-director of Texas Children’s Fetal Center. “Our program has grown exponentially since we completed our first NTD repair in 2012, and we remain cautious, but it seems as though our center’s results are exceeding even those of the trial.”

The final piece to this puzzle is Dr. Kathryn Ostermaier, clinic chief of the Spina Bifida Clinic. It is under her guidance that the hospital provides long term care to surgical patients. The hospital’s Spina Bifida Clinic is a specialized program that serves only those patients with spina bifida, and includes several specialty services: orthopedics, neurosurgery, pediatrics, physical medicine and rehabilitation and urology.

The team that cares for NTD patients before birth, after birth and into childhood includes physicians from maternal fetal medicine, pediatric surgery, neurosurgery, anesthesiology, neonatology, pediatric radiology, cardiology, orthopedics, urology, physical therapy, and a highly dedicated group of specialized nurses, ultrasound technologists and genetic counselors.

“The confirmation that fetal surgery may decrease the physical challenges some of these babies face is not only a ray of hope for families, it is also a significant achievement for fetal medicine,” said Cass.

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Intestinal worm infections rank among the most common afflictions of people living in extreme poverty, with reports of more than 800 million people who are harboring Ascaris roundworms in their gastrointestinal tract, and approximately 450 million people who are infected with either hookworms or Trichuris whipworms. These numbers suggest that almost every person living in a developing country is infected with worms, a consequence of the fact that the infective egg or larval stages of these parasites are practically ubiquitous in the soil.

“Each type of worm brings its own little shop of horrors,” said Peter Hotez, President of the Sabin Vaccine Institute and Texas Children’s Hospital Endowed Chair in Tropical Pediatrics.

While the World Health Organization (WHO) is leading a global campaign to “deworm” via mass drug administration at schools, Texas Children’s Hospital is pioneering the development of new worm vaccines.

According to Hotez, one of the problems with deworming is rapid post-treatment reinfection. There also is information to suggest that while the drugs work well on some worms, others such as hookworm and Trichuris whipwork are more resistant. And while deworming is one of the world’s largest global public health programs, so far less than 40 percent of the world’s children who could benefit from deworming actually receive the medicines.

“There is a lot of work to do,” said Hotez. “Global deworming needs to continue to scale-up and expand. We also need research into better drugs and vaccines, especially for hookworm.”

The Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development have been working to do just that. The hookworm vaccine they developed is now in clinical trials in Brazil, and will soon enter clinical testing in Gabon. And a schistosomiasis vaccine is about to undergo phase 1 trials for safety and immunogenicity here in Texas. They are also pursuing the possibility of a vaccine that could target all of the intestinal worms.

Worms can result in severe health consequences for growing children and, in the case of hookworms, also for pregnant women. Recently, the Global Burden of Disease Study that evaluated almost all disease conditions for the year 2010 determined that intestinal worms cause as much or more global disability than better known childhood conditions such as autism, ADHD, or cleft-lip and palate. Hookworms accounted for more than two-thirds of that disability. There have also been occurrences of some unique worm infections here in Texas, including toxocariasis and cysticercosis, which is associated with epilepsy and other brain disorders. It’s important to be aware of these diseases and spread word about their dangers, in order to raise awareness and funding to fight intestinal worm infections in developing countries and at home.

“Worm vaccines would represent important new global health technologies in order to improve the health and vigor of children in the world’s poorest countries,” said Hotez. “A world free of worms would be one in which children achieve their full physical, intellectual and economic potential.”

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We are looking back to the 1960’s this month and invite you to share your favorite Texas Children’s memories. Read more

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When my husband and I first heard the news that our unborn daughter had CDH (congenital diaphragmatic hernia), time stood still in what seemed like a dense fog. As many would do, I ran to internet sites like Google and Wikipedia to find out more about this sometimes fatal abnormality. I was inundated with medical terminology and survival statistics. I was able to create a huge binder with all of the research I had done and carry that stack of documents with me to every appointment we had. Needless to say, I thought I was prepared for the various outcomes we could experience after our little girl was born.

On November 28th, 2010, Brooklyn Elizabeth Hales was born one day shy of her Father’s birthday and one month short of her due date. She was immediately intubated and taken to the NICU III in West Tower. For the next few weeks she struggled with stability and even ended up on ECMO. There were many dark moments in those first weeks of her life, but like I said before, we knew what we were up against. We knew that the ugly road of CDH was not an easy one, and we had prepared our hearts for heartbreak.

What we hadn’t planned for, and what never even came to mind, was how we would cope with “NICU life.” In the four months of Brooklyn’s hospital stay, I spent majority of my time at her bedside, walking the halls of West Tower, or trying to catch some rest in the Ronald McDonald House on the fourth floor. I lived, breathed, and smelled like the NICU. I had a fully organized folder on what Brooklyn could be faced with, but I had an empty hand when it came to information on how to navigate my role as a parent in the NICU. As a parent, you are your child’s most valuable advocate. You have intuition and you will spend the most time with your child. But how do you know which beep means business? Or how do you know when to speak and when to be quiet?

Or… what if my child’s pod mate passes away?
These are all questions and scenarios I had to navigate thru as a first time NICU parent. The one thing I learned over anything else when living in the NICU is that there’s a lot you CAN prepare for, and a lot you CAN’T prepare for.

As an employee of Texas Children’s, I know that we are constantly seeking out opportunities to better our families and their experiences. And as a NICU parent, I am even more excited about the creation of a new resource class available to our parents. A few months ago I had the privilege to brainstorm with the creators of the class, Preparing for Your Newborn’s Hospitalization. The purpose of our meeting was to gain the perspective of a NICU parent and bring up what could have been helpful prior to that “NICU life.” This class, with the help of its leaders and speakers, will better prepare those parents who are awaiting their newborn’s stay. I feel that had this been at my disposal prior to Brooklyn’s birth, I would have been one of the first to sign up. I believe it will be a tremendous value to our parents and great addition to the many great classes provided by the Pavilion for Women.

To sign up for “Parenting your hospitalized baby” or any of the other classes available to Pavilion patients, visit: http://women.texaschildrens.org/Patient-Education/

March 25, 2014

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March 21, 2013 was the day our relationship with Texas Children’s Hospital changed. My husband, Matt, and I are both employees at the hospital, so Texas Children’s is very near and dear to us. We have enjoyed our many years serving our patients and working with the wonderful employees of this organization. I have been a nurse here for 16 years and my husband has worked here for 13 years, currently in the Texas Children’s Heart Center. We’ve spent so many days throughout the years walking the halls of Texas Children’s doing what we love, but on March 21 we realized we were going to be experiencing the hospital as parents, not just as employees.

Luke, our unborn son had been diagnosed with a congenital heart defect – coarctation of the aorta. The fetal cardiac imaging team at Texas Children’s detected this defect through a fetal echocardiogram. This enabled them to see the function of Luke’s tiny heart, at just 22 weeks gestation! Although in disbelief, we were thankful for this early detection as it was critical for many reasons. Not only did it help the medical teams plan for Luke’s delivery, but it also allowed Matt and me to ask questions and fully understand the defect and how it might impact him. Even though we work in health care, we had so many questions and were increasingly anxious about the health of our son. Between our wonderful OB, Dr. Kimberly Bobo, at Texas Children’s Pavilion for Women, and the Heart Center and Fetal Center teams, we felt less anxious and certainly very prepared for the possibilities. We were comforted by the countless support staff and multidisciplinary experts we worked with for the months leading up to Luke’s birth. We were never treated as if our questions and concerns were naive and always felt as if each person we encountered was giving us their full attention and compassion for our situation.

As Luke’s birthdate neared, our excitement, as well as our fears grew – the unknown factors were many, but we knew that his care teams were as prepared as possible to handle any situation. His delivery was uneventful (thank goodness!) and there was a NICU team on hand to start his care immediately. He spent a few days in the NICU being monitored closely. Luckily, he remained stable and after a reassuring echocardiogram, we were sent home. It wasn’t until our one month follow up appointment that we learned the narrowing in his aortic arch had worsened and it was time for surgery.

No parent should ever have to experience their child going through heart surgery and the related recovery. It can be a frightening experience and one that we hope to never have to go through again. That being said, the team of experts at Texas Children’s who cared for Luke is among the best in the country. We found comfort in knowing that this is a very typical day for the surgical and medical teams who cared for Luke as they encounter highly complex cardiac patients on a daily basis and perform high volumes of surgical procedures just like Luke’s frequently. We knew he was in the best hands possible for a positive outcome.

32514TimmonsB640After a very long day of waiting while Luke was in the operating room, we learned his surgery was extremely successful and spent the next several days recovering with him in the cardiovascular intensive care and cardiac acute care units. Luke had an uneventful recovery period so we were able to take him home just a few days after his surgery. Since that time, we have been followed by his cardiologist and Luke is currently a very happy, healthy 7 month old boy.

We are so thankful for the numerous individuals who looked after Luke during this phase of his life and who continue to ensure he remains healthy. One of the reasons Texas Children’s is so remarkable is the sheer number of clinical and technical experts who are involved in the care of just one child. From cardiology, congenital heart surgery, obstetrics, maternal fetal medicine, cardiac imaging, critical care, and acute care, Luke encountered truly inspiring individuals who are experts in the care of children with congenital heart disease. As a parent, it is almost hard to believe that so many experts are available to us to care for our child. As fellow employees, we are proud to be a part of the amazing team at Texas Children’s and know that we are providing this level of care and compassion to all patients and families.

You can learn more about Luke’s journey by watching this video.

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Lindsey Gillespie, a Dallas nurse and mom of three young boys, was expecting a routine pregnancy to deliver her fourth child. But during a scheduled ultrasound to determine the gender of the baby, the nurse noticed something odd. After being fully evaluated, doctors suspected placenta percreta, the rarest and most severe form of placenta accreta. When Lindsey could not find a group who routinely treated cases like hers in the Dallas/Ft. Worth area, she eventually transferred her care to Texas Children’s Pavilion for Women in Houston.

And she’s not the only one. The Pavilion for Women has the largest and busiest program in the country for this condition, treating more than 60 cases in the last three years.

“What’s unique to others has now become routine to us,” said Dr. Michael A. Belfort, OB/GYN-in-Chief at Texas Children’s Pavilion for Women. “That strengthens the case for having this type of surgery done by a team that does it all the time and knows how to do it.”

Placenta percreta, the rarest and most severe form of placenta accreta, is a potentially life-threatening condition that can affect any neighboring uterine structure. Placenta percreta (5 percent of all placenta accreta cases) happens when the placenta grows entirely through the uterine wall and attaches to another organ like the bladder. When it involves the urinary bladder, a multidisciplinary approach utilizing a team of physicians and surgeons representing urology, radiology, and obstetrics/gynecology is the key to successful management. Moms who have had previous cesarean deliveries are at an increased risk to developing the condition.

According to the American College of Obstetricians and Gynecologists, in the 1980s placenta accreta affected 1 in 4,000 pregnancies. Today the rate has spiked, affecting 1 in 533 pregnancies – in large part due to the increased number of c-section deliveries.

This year alone, Belfort estimates that Texas Children’s Pavilion for Women will treat about 30-40 patients with placenta percreta, including Lindsey Gillespie. Five patients are currently awaiting surgery.

While Lindsey was at first nervous to leave her home and give birth in Houston, her husband reassured her she was making the right choice, saying “Wow, you couldn’t be at a better place. The hospital you are delivering at is connected to a children’s hospital, so if anything goes wrong it is right there. That is phenomenal!”

On March 14, Belfort led a team of physicians and neonatologists who performed an Indicated preterm Classical Cesarean section followed by Modified radical hysterectomy on Lindsey. She gave birth to a healthy baby girl and pulled through the surgeries without needing a blood transfusion. While the risks were high, Belfort and his staff were confident and well prepared, with a room full of high-risk physicians, neonatologists and a huge supply of blood, should she have needed a transfusion.

“The safest place to have this kind of surgery is in a place where they do it all the time, have a protocol, have a well equipped and practiced team and are comfortable with this issue,” said Belfort.

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When a boy arrived at Texas Children’s with massive, progressive swelling caused by a bite from a southern copperhead, toxicologist Dr. Spencer Greene knew just what to do.

“Doctors at an outside hospital minimized the significance of the bite and had no intention to treat him, even though he was very symptomatic,” said Greene. “We started antivenom, and he responded well. Not only is he back to playing sports and acting like a normal boy, he now is fascinated with snakes, which I think is pretty neat!”

32514toxicologist6403Greene’s passion for helping those who suffer from accidental poisonings and his enthusiasm for the obscure field of toxicology make him an exciting addition to our medical staff. He joined Texas Children’s as a consulting medical toxicologist this past October, and the timing proved fortuitous. Texas now leads the nation in number of snakebites per state, and with the addition of Greene, Texas Children’s boasts the only board-certified medical toxicologist in Houston.

But Greene’s role will extend well beyond the treatment of snakebites. He will diagnose and manage the effects of other poisonous or harmful substances that are hazardous to children and adolescents. Also board-certified in emergency medicine, he will be called upon for his expert opinions on treating accidental and intentional ingestions, toxic substance exposure, envenomation, occupational and environmental exposures or severe alcohol and drug abuse reactions. Greene also will continue his roles as director of medical toxicology and assistant professor of medicine at Baylor College of Medicine.“I consider my consultations to be an opportunity to educate everyone involved in the case, including the patient and/or his or her family, the nurses, the students, and the physicians,” said Greene. “By consulting on patients with toxicological emergencies I can help the admitting physicians and the doctors in the emergency department diagnose and treat patients efficiently and safely.”

Greene takes pride in collaborating with physicians from other specialties and using his unique fund of knowledge to help diagnose and treat patients with an illness or injury that is rarely encountered. His varied list of successful cases range from a young girl who ingested her father’s muscle relaxant and presented to the hospital with altered mental status, and a young man who was having a rare idiosyncratic reaction to the medications he had been given after sustaining a major trauma, to a high-profile case of a man with massive bee envenomation who was stung over 3000 times.

“Medical toxicology has a whole body of knowledge that is not commonly taught to most physicians, and often times toxicologists get to use this information to arrive at some pretty obscure diagnoses,” said Greene.

With his involvement, the goal is to reduce the amount of unnecessary testing that is often performed on patients with toxicological emergencies. Greene also hopes to dispel some myths that may surround toxicology patients and recommend therapy that is evidence-based rather than done “because we have always done it that way.”

In previous positions, such as his post as the program director for the University of Arizona Medical Toxicology Fellowship, Greene worked with adult patients who have chronic psychiatric illness or substance abuse, meaning even if he helped treat the acute toxicological condition, it was often only a matter of time before the patient returned with a similar emergency. He’s looking forward to focusing on pediatric patients, many of whom are victims of accidental poisonings and can expect a full recovery with proper treatment.

“It is very gratifying to know that I can make a real difference in my patients’ lives,” said Greene. “I hope that my involvement will help prevent poisonings at home and will give health care providers some information they can use whenever they treat toxicology patients in the future.”