April 15, 2014

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New study puts spotlight on tuberculosis in children

A recent article in the Wall Street Journal featured a study from researchers at Brigham and Women’s Hospital and Harvard Medical School suggesting that Tuberculosis (TB) affects about one million children worldwide, twice as many as previously estimated. At Texas Children’s, TB experts identified this major pediatric health issue years ago, stressing that children are much more likely to develop TB disease following infection than adults and bear a relatively larger share of morbidity and mortality than adults.

According to Dr. Jeffrey Starke, director of the Children’s Tuberculosis Clinic at Texas Children’s, these new numbers are a reflection of more sophisticated and accurate diagnostic methods, since TB is difficult to confirm microbiologically in children (the traditional methodology of diagnosis in adults). In addition, it wasn’t until 2012 that the World Health Organization (WHO) released its first ever estimate of children with TB.

Having accurate numbers for pediatric TB is critical for funding purposes, and the new estimates will help shed light on this epidemic. “People interested in child survival and the Millennium Development Goals are going to look for what diseases are causing most morbidity and mortality in the world,” said Starke.

Texas Children’s Global Health Initiative has been working to actively address barriers to the care of childhood TB and to expand the spectrum of services available to children with TB through the Children’s Tuberculosis Initiative at Texas Children’s. The program aims to use the tools of research, education and advocacy to prevent, diagnose and treat tuberculosis in children, in order to support an ultimate goal of TB elimination.

“TB in children is often missed or overlooked,” said Dr. Anna Mandalakas, director of the Global Tuberculosis Program at Texas Children’s. “TB is a preventable and curable disease, but child health care providers in the US and abroad often miss opportunities to prevent TB and often diagnose pediatric TB late, making treatment more difficult.”

The Global Tuberculosis Program is implementing two TB REACH projects funded by the Stop TB Partnership as a part of the WHO, with the objective to improve TB case finding in Lesotho and Swaziland. The projects use a GeneXpert-Rif technology, a relatively new diagnostic near-point-of-case test that has become an important tool for improving TB diagnosis in children.

Globally, up to 50 percent of children less than 12 months of age develop the disease and every day up to 200 children die from the disease. Young children, malnourished children, and children whose immune systems are weak, such as those with HIV infection, have an exceptionally high risk of developing severe and life threatening disease following infection. In areas of high HIV prevalence, tuberculosis is thought to be the main killer of HIV-infected persons.

Since children with HIV-infection are at increased risk of TB disease, the Global TB Program is working closely with Baylor International Pediatric Aids Initiative (BIPAI) to enhance TB clinical programs. Information learned from the BIPAI network promises to fill major gaps regarding the burden of TB disease in HIV infected children and adolescents.

“HIV has changed the landscape dramatically,” said Mandalakas. “The TB-HIV co-infection is a deadly combination leading to an increase in morbidity and mortality in children globally.”

But TB is not just a global problem. Tuberculosis remains an issue in industrialized nations too. In 2010, more than 11,000 cases of tuberculosis disease were reported in the United States, with an estimated incidence of 3.8 cases per 100,000 persons. Texas comprised 12 percent of all TB cases in the United States (the second highest burden of childhood TB among US states). And within the state, Harris County had more TB cases than any other county in 2012. This may be explained by the large population of immigrants in the area, as children with the greatest risk of having TB include those who were born in or have lived in another country, or those who have a parent that was born outside of the US.

“We had one day in our TB clinic where we spoke seven different languages,” said Starke. “We see people from all over the world, both people who developed TB after coming to the US, and those were infected with TB in their home country. Most children who immigrate to the US receive no testing and no screening for TB and many of them are coming from an environment where TB is common and can easily be spread.”

According to Mandalakas, any child who is exposed to an adult with TB should complete a detailed evaluation to make sure that they do not have TB. If TB is not diagnosed, TB-exposed children can reduce their risk of developing TB to negligible levels by taking TB preventive medicines.

“We can’t look at TB in isolation,” said Starke. “We have to look at the bigger picture, the people they are around, the community and the circumstances.”

April 8, 2014

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On March 27, the U.S. House of Representatives voted to delay the implementation of the ICD-10 coding system for hospitals and providers – which was to replace the current ICD-9 coding system – by one year. Originally, all hospitals and providers were to have implemented ICD-10 by October 2014. The new deadline for implementing ICD-10 is October 2015.

The Senate passed the legislation on April 1, and the bill was signed into law April 2. The law is called the Protecting Access to Medicare Act of 2014 and is effective immediately.

How Does This Affect Texas Children’s?

The hospital has been working on its education plan for providers for more than a year. The education component will move forward as planned.

Providers still can access the education modules that explain how the new coding system will affect their specialties, beginning this month.

What does change is the deadline to complete the education courses. That deadline has been extended to July 2015.

In the meantime, the hospital will continue to train its billing staff on the ICD-10 system, and will continue to make system upgrades to the hospital’s electronic health record (EHR). Those upgrades ensure that our EHR is compatible with the ICD-10 system.

By continuing with our efforts to make the switch to ICD-10, the transition will be that much easier come next October.

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.”

March 25, 2014

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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.”

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Out West is a story of tremendous growth. Over the past three years, Texas Children’s Hospital West Campus has been serving one of the fastest growing pediatric populations and as the population grows, so has the community hospital. To meet the needs of the community, the hospital has expanded its services already and continues to look at the patients to determine what programs, services and initiatives may make the most impact in West Houston.

More than 400,000 patients have taken advantage of the Texas Children’s brand of care provided through West Campus since it opened its doors in 2010. The campus which sits on 55 acres, houses 19 subspecialty outpatient clinics, inpatient hospital services and the only 24/7 dedicated pediatric emergency center in the West Houston area.

Most recently, West Campus opened a new eight-bed Pediatric Intensive Care Unit, allowing the hospital to accommodate patients with higher acuity. Because of the increasing demand for emergency care, the hospital also doubled the number of beds in the emergency center which is staffed by board-certified pediatric emergency medicine physicians. In addition, a 28,500-square-foot, state-of-the-art sports medicine clinic was built, which houses a 3,000-square foot gym, two x-ray rooms, three casting bay sand 16 exam rooms for seamless, patient-centered service. The new space houses advanced technologies, including robotic dynamometry for isokinetic testing, motion recording and analysis to enhance rehabilitation.

Texas Children’s Hospital West Campus has been successful for many reasons, including the dedicated staff. There are currently more than 500+ passionate, hard-working team members who care for patients each day. The team of nurses, child life specialists, imaging technologists, therapists, renowned physicians, and many others are specially trained to diagnose, treat and care for children.

The success story is in part due to the support of the West Houston community. From the beginning, leaders and staff have cultivated these relationships, ensuring that patient families know about the care that is being provided in their own backyard.

Don’t expect the growth to stop any time soon. As leaders and West Campus employees continue to assess the needs of patients, families and the community, they will determine what programs, services and initiatives are most beneficial in the community setting.