Medical NewsM E D I C A L U P D A T E F O R R E F E R R I N G P R O V I D E R S Summer 2013

New Website Is A Resource For MDs And Parents

& the Department of Pediatrics of the University of Connecticut School of Medicine

A Neurosurgical First at Connecticut Children’sThis spring, Chief of Neurosurgery Paul Kanev, MD, performed Connecticut Children’s first right craniotomy for modified hemispherectomy in a patient with epilepsy. While the case is the first done in Hartford, Dr. Kanev has performed the rare procedure 31 times in his 30-year career.

The goal of the procedure is “to eliminate all activity from the right hemisphere that could be causing seizures,” Dr. Kanev says. “Historically, that meant taking the whole hemisphere, but that isn’t done anymore. Now we leave the tissue in place but electronically disconnect the motor pathways contributing to seizure, leaving the corpus callosum intact.”

The procedure was developed in the early 1980s. Since then, it has been modified several times. In the early 1990s, Dr. Kanev became the first to use intraoperative ultrasound in order to minimize entrance into the fluid chamber of the brain. He published papers on the first eight cases he performed this way. “I use ultrasound as a gauge to identify the ventricle, to tailor the disconnection cuts and to monitor real-time the depth of the resection as I proceed,” Dr. Kanev says.

Avoiding the ventricle results in much less spinal fluid inflammation and minimizes

complications such as postoperative fever syndromes. Patients typically have a much shorter hospital stay.

One of the reasons the procedure is rare is that only a very small group of children are candidates. These are children who already have baseline weakness of the corresponding side and whose seizures remain uncontrolled despite treatment with every available medication, both alone and in combination. “In correctly selected patients, this procedure is the only thing that’s going to help them be seizure-free,” Dr. Kanev says. “Being seizure-free is more important than being off medication.”

Studies show that 85 to 90 percent of patients who have the surgery will stop experiencing seizures. Among Dr. Kanev’s first 30 patients, 29 are seizure-free and 25 are off medication. The one patient who is not seizure-free improved dramatically, going from 10 to 20 major seizures per day

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The Connecticut Children’s Medical Center website has been completely transformed, with a modern design, up-to-date pediatric health care information and simple navigation for ease of use. The Find a Physician feature allows referring providers and parents to look up physicians by name or specialty area, and users can browse the Our Care section by keywords for the most relevant clinical care information. By increasing the visual connection through photos and videos,

along with stories about Connecticut Children’s patients, families, medical staff and supporters, the new website will engage users in a variety of ways.

“Connecticut Children’s vision of making children in Connecticut the healthiest in the country is becoming a reality,” says Martin J. Gavin, president and CEO, Connecticut Children’s Medical Center. “It is our hope that referring physicians, parents and caregivers use the new

to just one or two brief staring spells.

The child did very well after the procedure, with no progression of weakness. She was discharged seizure-free 10 days after surgery and was more talkative and interactive with staff and family.

Dr. Kanev is also a clinical professor of neurosurgery at the UConn School of Medicine. He may be contacted at pkanev@connecticutchildrens.org.

PRESENTATION A previously healthy 15-year-old boy presented to Connecticut Children’s Waterbury at Saint Mary’s Hospital for an elective procedure. He had been referred by his community pediatrician, Bidarkote Somanath, MD.

In the course of the routine pre-procedure systems review, the patient admitted to an occasional sensation of his “heart turning over” and some light-headedness. This had occurred several weeks prior to this evaluation. On more direct questioning, his mother reported that a maternal uncle had died unexpectedly in his 40s. She hesitatingly confirmed that she had recently been diagnosed with Brugada syndrome and that an automatic implantable cardioverter defibrillator (AICD) had been placed to treat heart rhythm abnormalities and prevent sudden death.

In view of this unexpected information, an EKG was obtained from our patient. It showed first-degree AV block and some ST segment elevation with a slight J-elevation. These EKG findings were discussed with Olga Salazar, MD, one of Connecticut Children’s cardiologists. The EKG findings, in addition to his family history, raised the question of a possible diagnosis of Brugada syndrome in our patient.

DISCUSSION Brugada syndrome was first recognized by the eponymous Brugada brothers, both clinical adult cardiologists, in 1992. Initially Brugada syndrome was diagnosed only when patients presented with serious heart rhythm abnormalities, and therefore it was associated with a high risk of sudden cardiac death and fatal ventricular arrhythmias in young adults. Brugada syndrome has been diagnosed in neonates; however, most diagnoses are made in adulthood. This condition is more typically reported in males than in females and seems especially associated with Southeast Asian heritage. It is thought that increased exposure to testosterone places males at a higher risk. Another risk factor in some patients is periods of increased vagal tone (sleeping). It has been proposed as a possible cause of sudden unexplained nocturnal death syndrome in adults and SIDS in infants. The exact prevalence of Brugada syndrome is unknown, although it is estimated to affect possibly up to five in 10,000 people worldwide.

Clinical and genetic research conducted since the condition was first identified

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CASE REVIEW Pediatric Cardiology physician assistant James Gerace, PA-C, and Inpatient Management Team attending physician MacDara Tynan, MD, prepared this issue’s case.

suggests that Brugada syndrome may be more commonplace and not as malignant as was initially thought. At least eight types of Brugada syndrome have been identified, each associated with a different chromosomal abnormality.

Brugada syndrome type 1, which our patient’s mother has, is an autosomally dominant inherited defect. Type 1 is the most commonly diagnosed form of Brugada syndrome, accounting for approximately 25 percent of cases. It results from abnormal sodium channel transport in cardiac cells. Specifically, there is a mutation associated with Brugada syndrome found on the SCN5A gene, which is on the short arm of chromosome 3. This SCN5A gene mutation is more common among people of Southeast Asian descent. Sodium influx through these channels is responsible for the initial depolarization of the myocardial cells.

The characteristic EKG findings of Brugada Syndrome type 1 are J elevation >=2 mm (0.2 mV), a coved type ST segment elevation followed by a negative T wave, in two of the 3 right precordial leads V1, V2 or V3. (See example at right.)

Interestingly, these EKG changes are termed “dynamic” or inducible. Many patients with Brugada syndrome will have a normal EKG at baseline. These abnormalities on the surface EKG may become apparent only under certain conditions. Fever can bring out the characteristic EKG changes. Also, medications that affect the sodium channels, such as procainamide, may unmask these EKG changes. The procainamide challenge test is sometimes done under controlled conditions to assist in the diagnosis of Brugada syndrome. The exact roles of the procainamide challenge test and electrophysiologic studies in the diagnosis and prognosis of Brugada syndrome are evolving as we uncover more asymptomatic patients with genetic mutations associated with Brugada syndrome.

Consequently the clinical diagnosis of Brugada syndrome can be made when a type 1 EKG pattern (spontaneous or drug-induced) occurs in association with a personal history of syncope or aborted sudden cardiac death or in association with a family history of type 1 Brugada syndrome or sudden cardiac death. In approximately 78 percent of cases the SCN5A gene is found.

DIAGNOSIS/TREATMENT Our patient was further evaluated by Harris

Leopold, MD, Connecticut Children’s chief of Cardiology. The patient’s EKG was not diagnostic of Brugada syndrome type 1. A 24-hour Holter monitoring did not show any abnormal or concerning ventricular rhythms associated with Brugada syndrome. The patient was screened for the same SCN5A gene mutation that his mother was found to have. He was not a carrier. So he does not meet diagnostic criteria for Brugada syndrome type 1.

The treatment decisions for patients diagnosed with Brugada syndrome are evolving as we try to risk-stratify patients who may benefit from AICD implantation. Aborted sudden death, clinical episodes of ventricular tachycardia and family history seem to correlate with higher risks of sudden death and therefore justify AICD implantation. Isolated genetic mutations without clinical episodes, procainamide challenge positive patients and electrophysiology studies have less predictive value.

Drug therapy has not been shown successful in preventing sudden death. AICDs are used for high-risk patients. However, AICDs may cause complications, including psychological issues, inappropriate discharges and, rarely, local site erosions. These are important to address in the risk/benefit analysis of the treatment of Brugada syndrome.

Have you had an interesting case involving Connecticut Children’s?

Contact Medical News Managing Editor Dennis Crean, RN, at 860.837.6248 or

dcrean@connecticutchildrens.org.

“Oh, And By The Way ...”V1-V3 Normal

V1-V3 Brugada

type1

New Website Is A Resource For MDs And Parents, continued from page 1

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RESEARCH

Preparing the Clinical Researchers of TomorrowUndergraduate pre-med students at the University of Connecticut are gaining valuable experience in clinical research, thanks to an innovative program offered by UConn and Connecticut Children’s Medical Center.

The Undergraduate Research Assistant Program, or URAP, originated with Sharon Smith, MD, who serves as research director for the Medical Center’s Emergency Department. What started as an informal arrangement by which Dr. Smith mentored one or two students is now an undergraduate laboratory course called Introduction to Translational Research that enrolls 15 students a semester. Dr. Smith is the course director.

“I go to Storrs for two hours a week and lecture or arrange lecturers on study design, statistics and how to enroll subjects,” Dr. Smith explains. “We invite investigators to come and tell the students about the background for their studies.” Using instruction and role-modeling, Dr. Smith teaches students how to enroll patients in studies. Then they practice their skills in the real world of Connecticut Children’s Emergency Department.

The students are all juniors or seniors in

website as an everyday resource and decision-making tool when it comes to caring for children across Connecticut.”

The new site features a library with more than 6,000 pages of health information on topics ranging from asthma, bullying and heart surgery to Kawasaki disease

and healthy lunch ideas. This health information is specially written for parents, teens and kids, using clear, concise language that is appropriate for different age groups.

Referring providers can keep up with Connecticut Children’s CME courses,

educational seminars, quality and safety initiatives, and our latest research findings in sections headed For Health Care Professionals, Education & Training, Quality, and Our Research. For more information, visit www.connecticutchildrens.org.

UConn’s Honors Program. They take the introductory class in the first semester and have the option of the senior-level class in the second. Students in the introductory class spend a minimum of four hours a week at Connecticut Children’s, while senior-level students come six hours a week. It doesn’t take long before the students, easily recognized by their green scrub shirts with URAP on the pocket, are part of the ED community. “Everyone knows who they are,” says Dr. Smith. “The staff is good about including them. They’ll bring them over to look at interesting X-rays or see a laceration repair. A couple have been invited into the OR. They’re starting to learn a little bit about medicine.”

The Medical Center’s ED has 10 active research studies under way, and the students play a key role by enrolling subjects—something busy physicians and nurses typically don’t have time to do. When a patient seems to be a likely candidate for a study, Dr. Smith or a member of the ED staff goes into the exam room and gets the parent’s permission to invite in the student. “The students are so scared when they first start, but by the end of the semester, the ED is like their home. They know the

place, and they know all the people,” Dr. Smith says. “It’s really fun to watch them mature throughout the semester.”

Senior students often do their own research studies. Dr. Smith mentors them through developing the idea and writing the protocol. She accompanies them when they present to the review committee and helps them write their IRB proposals. The process has been effective. “We’ve had three first-author publications from students,” Dr. Smith says.

URAP is a classic win-win situation. “We want to be academic, ask questions, make a difference in practice and benefit children in the community, but we don’t have time to enroll subjects,” Dr. Smith says. “So the students come in and, while we’re taking care of patients, they’re in and out of rooms, meeting patients who are happy to help. We get a tremendous amount of research work accomplished, and students get a chance to see what it’s like to be a doctor.”

Dr. Smith is also associate professor of pediatrics at the University of Connecticut School of Medicine. She may be reached at srsmith@connecticutchildrens.org.

Physician Of The Year NamedCatherine Wiley, MD, medical director of Primary Care at Connecticut Children’s, was chosen by her peers as the Medical Center’s physician of the year. She is associate professor and division head of General Pediatrics at the University of Connecticut School of Medicine. In announcing Dr. Wiley’s selection, colleagues said she “represents the ideal of a primary care pediatrician,” providing exemplary care to “many of our most

medically complex patients.” They cited her leadership in serving as medical director of Charter Oak Health Center at Connecticut Children’s and on several hospital committees. She promotes literacy through her leadership in Reach Out and Read and advocates for children and families by promoting the Medical Home model and founding the Primary Care Center Advisory Board at Connecticut Children’s. Congratulations to Dr. Wiley on this honor. Dr. Wiley with a patient.

Featured SubspecialistJohn Brancato, MD, doesn’t hesitate when asked why he chose to specialize in pediatric emergency medicine. “I love the variety and the ‘puzzle’ part of it,” he says. “When patients come in with whatever complaint,

we need to use the history, physical exam and sometimes additional means to make a diagnosis or rule out serious things.” Like most ED physicians, he says, he’s a high-energy person, and that makes him well-suited to caring for children with acute medical or surgical problems in a busy Emergency Department like Connecticut Children’s.

Dr. Brancato joined Connecticut Children’s Emergency Department in 1998 after completing his fellowship at Boston City Hospital. He is assistant professor of pediatrics and emergency medicine at the University of Connecticut School of Medicine. In 2012, Dr. Brancato became associate director of the ED. As associate director, one of the things he’s chosen to work on this year is strengthening and

improving the department’s relationships with referring providers. “I think it’s good, but it can always be better,” he says. “We value that connection, and the best care for the patient depends on our having good communication with referring physicians. It’s not only about good verbal communication, but also understanding our respective capabilities.”

Emergency medicine subspecialists, he notes, are uniquely qualified by their years of specialized training and their experience to accurately and effectively evaluate and manage patients with acute illness or injury. “My colleagues are very skilled,” Dr. Brancato says, adding that these highly trained physicians have broad knowledge about the whole range of organs and systems. Referring providers can trust that when they refer a patient to the Medical Center’s ED, the patient will receive high-quality assessment and care.

Sedation is one of Dr. Brancato’s chief clinical interests. He and his colleagues in the ED do their own sedation to keep children comfortable or still during painful or delicate procedures. Sedation is a way “you can really make a big difference in managing pain and fear for patients,” he says. “There’s a science to it and an art. You need to know

how to vary the medications based on the patient and the procedure. I like the part that’s not cookbook—that really depends on your experience.” Dr. Brancato serves on the Medical Center’s Sedation Committee and, with Drs. Len Comeau and David Marcello, taught at the sedation course held at Connecticut Children’s last fall. He frequently lectures on pediatric sedation and other pediatric emergency medicine topics at area hospitals.

Dr. Brancato directs the Pediatric Emergency Medicine Fellowship Program at Connecticut Children’s. He enjoys working closely with the fellows and coordinating their clinical, research and administrative experiences. “I want to be sure they get the best overall training possible,” he says. Two former fellows, Drs. Zoe Casey and Kristin Welch, are now attending emergency medicine physicians at Connecticut Children’s, and both are “really excellent,” Dr. Brancato says. He’s directed the program for more than 10 years. “It’s really rewarding knowing that our graduates are contributing to the quality emergency care of children here and in many other parts of the country.”

Dr. Brancato may be reached at jbranca@connecticutchildrens.org.

John Brancato, MD

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Down Syndrome Program Complements CarePrimary care providers, subspecialists and parents have a valuable local resource to turn to for help in meeting the unique needs of children with Down syndrome: the Comprehensive Down Syndrome Program. Launched late last year by Connecticut Children’s in collaboration with the Connecticut Down Syndrome Congress, the program is the first of its kind in the state.

“The goal of the Comprehensive Down Syndrome Program is to address and integrate all aspects of a child’s developmental care, including medical, emotional, behavioral, educational and psycho-social needs,” explains Robert Greenstein, MD, Connecticut Children’s medical director of the program and professor of genetics and pediatrics at the University of Connecticut School of Medicine. The program seeks to ensure

that patients with Down syndrome experience integrated, coordinated, continuous care.

“We are a consultative service,” says the program’s care coordinator, Jennifer Semmel, BSN, RN. “We don’t take over the PCP role; we complement it. There are many different medical issues that can occur in a child with Down syndrome. We are a resource to providers to help ensure that everything is being done to maximize a child’s potential.”

Some children referred to the program for consultation are seen only once a year. Children with more complex issues are seen more often. So far, many patients have been referred because of medical issues such as hypothyroidism, gastrointestinal problems or feeding difficulties. Others have been referred for behavior and transition issues, especially

related to school. “Children with Down syndrome have a lot of difficulty with transitions,” Ms. Semmel says. “If they’re not prepared for change in advance, they can experience a lot of stress.” One of the program’s goals is to educate health care providers and school systems about the need for transition plans for children with Down syndrome.

Dr. Greenstein can also link doctors and families with helpful resources, including programs offered by the Connecticut Down Syndrome Congress. As a geneticist and pediatrician for many years, Ms. Semmel says, Dr. Greenstein is “a wealth of information.”

Dr. Greenstein and Ms. Semmel see patients on Fridays at 100 Retreat Avenue in Hartford. To refer a patient, call Rachel King at 860.837.5237. To learn more about the program, call Ms. Semmel at 860.837.5237.

Mission: Global Health CareAfter Haiti was devastated by a massive earthquake in 2010, Connecticut Children’s emergency medicine and critical care specialist Adam Silverman, MD, flew to the impoverished nation to help. Since then, he has gone on five medical missions to Haiti and organized several more. Now Dr. Silverman, along with a group of colleagues, is launching the Global Healthcare Project, an initiative he hopes will result in many more clinicians from Connecticut bringing medical care to places that need it so much.

“We see this project as a way of encouraging increased participation by Medical Center staff in global health care endeavors,” Dr. Silverman says. He adds that there are many ways for community physicians to get involved, as well, and he invites them to contact him for more information.

Another part of the Global Healthcare initiative is establishing long-term relationships with hospitals and health care providers in Haiti. “It’s hard to have trust and collaboration when you go only once or once a year,” Dr. Silverman says. “But if the institution can provide that long-term relationship, individuals can fill in.”

He and others from Connecticut Children’s have worked at Hospital Bernard Mevs in the Haitian capital of Port Au Prince. Having an ongoing relationship makes all the difference. “They know us, they know Connecticut Children’s, our level of expertise and the spirit in which we come, so we can be much more effective with Haitian doctors and nurses than someone who comes only once,” Dr. Silverman says.

This fall, Dr. Silverman is taking a team to Hospital Universitaire Justinien in Cap-Haitian to pilot a program to increase the capacity of Haitian doctors who care for the sickest children in the country’s north. The pilot is a collaboration among Connecticut Children’s, the local hospital and a Maine-based charitable organization called Konbit Sante.

THE NEED IS GREAT Dr. Silverman says that clinicians traveling to Haiti for the first time can

the rainy night, screaming for help. People directed her to the hospital. On arrival, the child was unresponsive, hypothermic, hypotensive and still seizing. Dr. Silverman and his team administered anti-seizure medication, surrounded her with hot-water bottles and started her on medication to make her heart beat more strongly. They administered antibiotics, in case of infection.

“After two hours of aggressive resuscitation, she opened her eyes and smiled and said, ‘bonjour,’” Dr. Silverman recalls. “We could see she was getting better. We carried her to the pediatric ward, and within 24 hours she was sitting up and coloring in coloring books.”

LOOKING AHEAD Dr. Silverman hopes that more area clinicians will bring care to people like that little girl. So far, he and his colleagues spearheading the Global Healthcare Project have surveyed staff members about their medical mission experience, continued to organize additional missions, are developing new relationships with Haitian health care facilities and are creating a website to help people learn about opportunities. He spoke on the subject at a recent disaster-preparedness conference and plans to apply for grants to fund more opportunities to get the word out.

For more information about the Global Healthcare Project or medical mission opportunities, contact Dr. Silverman at asilverman@connecticutchildrens.org or 860.545.9805.

expect a significant culture shock. “Port Au Prince is only 90 minutes from Miami, but it is one of the most underserved places in the world,” he says. “The difference in the lives of those people from those in the United States is just astounding.”

While Hospital Bernard Mevs serves both adults and children, Dr. Silverman and others from Connecticut Children’s provide mostly pediatric care. Perinatal infections are quite common, so many children have hydrocephalus, and there is a dearth of neurosurgeons to treat it. Respiratory illnesses, infections and major and minor trauma are also common. Many infants are born at home or in tents, and mothers and babies often have fevers. There are no laboratory facilities to do cultures, so visiting clinicians treat infection with whatever antibiotics are available and hope it will be effective. Access to radiology studies is limited. There is a CT scanner that sometimes works, but there are no radiologists.

“We’re on our own there, but many people find it inspiring and liberating to realize how effective they can be without those tools,” Dr. Silverman says. “We can actually provide pretty good care with a lot less.”

A MEMORABLE CASE Some cases stand out in Dr. Silverman’s memory. One is that of a 2-year-old girl he cared for on his second trip to Haiti in October 2011. The child had a seizure. With no way to call for help, the little girl’s mother carried her in her arms through

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At the hospital in Haiti, Dr. Adam Silverman transports a child from the ICU to the pediatric ward after treatment for seizure, hypothermia and hypotension.

F E A T U R E D S U B S P E C I A L T Y

Hematology/Oncology EvolvesSince Nathan Hagstrom, MD, director of Connecticut Children’s Hematology/Oncology Division, came to Connecticut Children’s 15 years ago, the program’s

clinical staff has more than doubled to include eight physicians, five outpatient nurse practitioners, four inpatient nurse practitioners, 14 nurses, three social workers, six research assistants, a child life specialist and three medical assistants. In the same time frame, Dr. Hagstrom notes, “The number of cancer patients the program sees has doubled, and the number of new patients referred to us has more than doubled.” In addition to cancer, Connecticut Children’s Hem/Onc Division cares for children with all manner of blood disorders, including anemia, bleeding disorders, leukopenia and thrombosis. Dr. Hagstrom says, “Our hematology service has grown the most. When I came, we didn’t have a sickle cell center, as we do now. Our hematology practice, especially bleeding disorders and thrombotic disease, has grown three-fold.”

The program has grown its clinical trials significantly as well. “We’ve expanded both the number of available studies and the breadth of new agents and have extended to diseases other than cancer, such as sickle cell disease, hemophilia and immune thrombocytopenic purpura. The number

of patients we are enrolling on studies has nearly tripled,” Dr. Hagstrom says. In addition to novel new cancer agents targeted to the cell machinery that causes cancer, he and his colleagues are planning clinical trials on new, longer-acting factor concentrates for treatment of hemophilia. The new factors have a longer half-life, so they allow for less-frequent infusions. They also have a trial open for a new drug for sickle cell disease.

Their new program for advanced cancer care and research brings together superb and compassionate care and the latest in scientific advances. “We provide hope and alleviate suffering using an interdisciplinary, compassionate team approach and the most advanced treatment protocols and scientific technology,” Dr. Hagstrom says.

For patients with immunodeficiency, the newest treatment is subcutaneous immunoglobulin replacement at home. The patient—or parent—inserts the needle under the skin and slowly infuses the IgG. The treatment is done weekly. There are two benefits: First, patients don’t have to come to the hospital or have IV access, and second, it gives a more even level of protection. “IV is every four weeks, so there are bigger peaks and troughs,” says Dr. Hagstrom. “We think the new therapy provides better protection against infection.”

The division has a new Clinical Care Center for Cancer and Blood Disorders, featuring eight private infusion rooms, a family resource room, a teen room, a play area, a laboratory and more. The center

was designed with input from patients and families and using Lean-Six Sigma methodologies. It has been very well-received by patients, families and staff. “Our patient and family experience has always been great, but now it’s the best,” says Dr. Hagstrom.

The program also has launched an Adolescent and Young Adult Cancer Program for patients ages 16 to 30. “We see these patients and provide them with comprehensive care and admit them here for treatments because they have cancers unique to a younger age group, and we’re the best equipped to take care of them,” Dr. Hagstrom says. “Plus, we have more clinical trials available to this age group than most adult cancer centers.”

The Medical Center expanded the cancer and blood disorders programs so that fewer patients would need to be referred out of state for care. One of Dr. Hagstrom’s goals is to continue to make his department’s high-quality care readily available to children throughout Connecticut who have cancer or blood disorders. He and his colleagues see patients at the main campus in Hartford and at satellite facilities in Shelton, Danbury, Glastonbury and Farmington, and he hopes to expand the division’s presence in southwestern Connecticut in the future.

Dr. Hagstrom is also associate professor of pediatrics at the UConn School of Medicine and director of the UConn Hemophilia Treatment Center. He may be contacted at nhagstr@connecticutchildrens.org.

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Nathan Hagstrom, MD

Morning Check-in Promotes SafetyEvery morning, staff members throughout Connecticut Children’s participate in a structured, efficient, 15-minute phone call aimed at ensuring the highest possible level of patient safety. The call is one component of a patient safety initiative the Medical Center is conducting in collaboration with the Connecticut Hospital Association. The initiative is based on the national Safety Starts with Me program.

“This is a journey to high reliability in patient safety—the right thing done the right way every time,” says Andrea Benin, MD, senior vice president for patient safety and quality at Connecticut Children’s. The Medical Center is one of approximately 500 hospitals nationwide participating in the program, which involves instituting a

awareness and shared accountability.” Before the call ends, there’s a plan for how to address the issue.

The call, combined with other elements of the initiative, has proven effective. Dr. Benin says that most hospitals that have instituted the program have seen a 60 to 80 percent decline in the rate of serious safety events. The Medical Center averages one serious safety event every 30 days.

Connecticut Children’s is conducting training in all areas to engage staff in the initiative. Plans call for referring providers to participate in training in the future.

For more information, contact Dr. Benin at abenin@connecticutchildrens.org.

series of behaviors that enhance safety. The behaviors are summarized in the acronym, CHAMP: Communicate clearly, Handoff effectively, Attention to detail, Mentor each other, and Practice and accept a questioning attitude.

Engaging in a daily morning check-in call is part of the initiative. It’s called the Triple-L call, for Look forward, Look backward and Leadership awareness. Each clinical area gives an approximately 30-second report, mentioning any safety or quality concern that’s come up in the previous 24 hours or issues that may be on the horizon. “It may be an adverse patient event or a medication room door lock problem or a concern about staffing, for example,” says Dr. Benin. “With everybody present, we have shared

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Grand Rounds OnlineRemember that Grand Rounds Online is now FREE of charge.

Earn CME credit from your home or office by accessing selected Grand Rounds presentations online.

To register and obtain a password, call Deirdre Palmer at 860.837.6281.

Standard Schedule:5:30 p.m. to 6:00 p.m. – Registration5:30 p.m. to 6:30 p.m. – Buffet Dinner6:30 p.m. to 7:30 p.m. – Lecture7:30 p.m. to 8:00 p.m. – Q&A

Continuing Medical Education ProgramsAll programs are held at the Pond House Café, 1555 Asylum Ave., West Hartford, Conn.

Expanded Schedule:**5:30 p.m. to 6:00 p.m. – Registration5:30 p.m. to 6:30 p.m. – Buffet Dinner6:00 p.m. to 8:00 p.m. – Lecture8:00 p.m. to 8:30 p.m. – Q&A

To register or obtain more information, contact Diane Mouradjian at 860.837.6264 or dmouradjian@connecticutchildrens.org or Deirdre Palmer at 860.837.6281 or dpalmer01@connecticutchildrens.org

Team Approach Benefits Babies With PRSConnecticut Children’s multidisciplinary Craniofacial Team has extensive experience evaluating and treating babies with the various conditions associated with Pierre Robin sequence, such as cleft palate, micrognathia and glossoptosis. The Craniofacial Team has managed hundreds of babies with PRS over its 25 years. Historically, PRS babies would fall into three categories: those with severe respiratory distress who needed tracheostomy; those with moderate respiratory distress that could be controlled with positioning in a NICU setting until the jaw grew out; and those with minor respiratory distress, who were able to go home on a monitor. However, in 2010, the team began treating specific babies with PRS by performing mandibular distraction osteogenesis. MDO is a state-of-the-art procedure that is considered an excellent alternative for some babies who do not need a tracheotomy but do need intervention in order to improve respiratory and feeding issues. MDO solves both.

Determining the optimal treatment for each baby is a complex process that requires the expertise of a multidisciplinary team, coupled with a carefully crafted algorithm. Fortunately for these babies and their families, Connecticut Children’s has both.

“These are very complicated patients,” says

Kerri Langevin, MSN, APRN, PNP-BC, the team’s pediatric nurse practitioner and clinical coordinator. “No two patients are the same. So we need to follow and monitor them until we see what they’re going to need. We have adapted and developed an algorithm that guides our decision-making on how best to evaluate and treat babies with PRS.” Nicole Murray, MD, of Otolarynology and Kelly Mabry, PhD, CCC/SLP, of Speech-Language Pathology, spearheaded the algorithm’s development.

The Craniofacial Team is led by Co-directors Charles Castiglione, MD, of Plastic Surgery and Paul Kanev, MD, of Neurosurgery. It includes clinicians from Otolaryngology, Oral-Maxillofacial Surgery, Speech-Language Pathology, Dental, Orthodontics, Developmental Pediatrics, Social Work and Nursing. Babies with PRS demand teamwork, so staff from numerous areas, such as NICU, PICU, Anesthesia, Operating Room, Radiology and floor units participate in the care of these babies.

The team, working with the NICU staff and others, will try several interventions, such as a nasal trumpet or various positions, to try to ease the respiratory and feeding problems the disorder causes. If surgery to perform mandibular distraction is ultimately indicated, it’s typically performed when the baby is six weeks old.

Oral-maxillofacial surgeon Richard Bevilacqua, DMD, MD, performs the actual distraction. Under general anesthesia, the mandible is surgically separated and a distracter device is placed intraorally on the patient’s mandible. External pins are connected to the device, and the pins are turned frequently over a period of time until new bone grows to fill the space. The procedure is highly effective. “Babies are usually discharged within two weeks taking nearly 100 percent of their nutrition orally,” Ms. Langevin says.

Throughout the process, a constellation of medical and surgical professionals focuses on evaluating, treating and following up on the baby and supporting the family. “We work together on these babies very closely,” says Ms. Langevin. “That helps with the cohesiveness of care.” She adds: “We’ve had great outcomes and no major complications. I think that’s because our experience and team care has evolved. The babies have extensive workups, and the parents are kept informed every step of the way. We also have a very cohesive team component you don’t see at every hospital.”

For more information about the Craniofacial Team, contact Kerri Langevin at 860.545.9360.

Andrulonis Child MentAl heAlth evening leCture series

Oct. 8, 2013** Pediatrics-Child Psychiatry Co-Management of Early-Onset Anxiety and Depression in Primary

Care Practice

Jan. 14, 2014 Youth Suicide: Epidemiology and Prevention

March 11, 2014** Bullying and Cyberbullying in the Pediatric

Neurology Population

May 6, 2014** Psychopharmacology: Update for 2014

PediAtriC evening leCture seriesSept. 12, 2013**

Co-Managing Concussion

Nov. 21, 2013** Lyme Disease and Co-Infections: 2013 Update

Feb. 13, 2014** Recognizing Sepsis

April 3, 2014** Co-Management of Premature Adrenarche

Childhood isn’t always carefree. Kids often face big issues that can alter the course of childhood and overall wellness. As professionals, we need to be able to identify and overcome these hurdles before the repercussions become life-changing. Come gather with your colleagues to discuss current issues facing pediatric wellness and strategies to help kids reach their maximum potential.

Speaker Topics:Childhood Diabetes, Mental Health: Identifying At-Risk

Youth, The Growing Resistance to Antibiotics, Non-Accidental Traumas, Skin and Rashes,

and a Motivational Humorist

For more information visit:www.connecticutchildrens.org/pediatricwellness

or860-545-8690

Connecticut Children’s Medical Center282 Washington Street Hartford, CT 06106

NONPROFIT U.S. POSTAGE

PAIDHARTFORD, CT

PERMIT NO. 3745

Inside Glance...Case Review .......................................................2

Preparing the Clinical Researchers of Tomorrow .........................................................3

Physician Of The Year Named .............3

Featured Subspecialist ...............................4

Down Syndrome Program Complements Care .......................................4

Mission: Global Health Care ..................5

Featured Subspecialty ................................6

Morning Check-in Promotes Safety 6

Team Approach Benefits Babies With PRS ...............................................................7

Continuing Medical Education Programs ...............................................................7

Grand Rounds Online ..................................7

Medical NewsM E D I C A L U P D A T E F O R C O M M U N I T Y P H Y S I C I A N S

Medical News is also available online

Connecticut Children’s Medical Center At Your ServiceConnecticut Children’s provides a variety of services at locations statewide and beyond. Here’s a summary:HOSPITALS Hartford Connecticut Children’s Medical Center 282 Washington Street Hartford, CT 06106

Waterbury Connecticut Children’s – Waterbury Saint Mary’s Hospital 56 Franklin Street Waterbury, CT 06706

NEONATAL INTENSIVE CARE UNITS (NICU) Hartford Connecticut Children’s NICU Hartford Hospital 80 Seymour Street Hartford, CT 06106

Farmington Connecticut Children’s NICU at UCONN Health Center 263 Farmington Avenue Farmington, CT 06032

AMBULATORY SURGERY CENTER Farmington, CT – opening Fall 2013

SPECIALTY CARE CENTERS The Children’s Health and Wellness Center 79 Sandpit Road Danbury, CT 06810

95 Reef Road Fairfield, CT 06824

399 Farmington Avenue Farmington, CT 06032

310 Western Boulevard Glastonbury, CT 06033

4 Corporate Drive, Suite 282 Shelton, CT 06484

OTHER LOCATIONS East Hartford 111 Founders Plaza East Hartford, CT 06108

Farmington 11 South Road Farmington, CT 06032

Hartford 100 Retreat Avenue Medical Arts Building Hartford, CT 06106

New Britain The Hospital of Central Connecticut 100 Grand Street New Britain, CT 06050

New London Lawrence & Memorial Hospital 365 Montauk Avenue New London, CT 06320

Putnam Day Kimball Hospital 320 Pomfret Street Putnam, CT 06260

Stamford Stamford Hospital – Tully Health Center 32 Strawberry Hill Court Stamford, CT 06902

Torrington Charlotte Hungerford Hospital 157 Litchfield Street Torrington, CT 06790

Waterbury Waterbury Hospital 64 Robbins Street, 3rd Floor Waterbury, CT 06708

Springfield, MA Shriners Hospital for Children 576 Carew Street Springfield, MA 01104

Medical Editor John Brancato, MD

Managing Editor Dennis Crean, RN

Editorial Board Brendan Campbell, MD, MPH Kelly Coffey Susan Duckworth Robert Fraleigh Donald Hight, MD Harris Leopold, MD

Writer Noreen S. Kirk

Designer Edmond Jalinskas

Photographer Michael McCarter

Physician Liaison Diann Bailey, RN

WWW.CONNECTICUTCHILDRENS.ORG

To make an

appointment, call

the specialty’s main

number found at

Welcome Aboard We are pleased to announce this new addition to our medical staff.

Valerie Cote, MD, CM, FRCS(C)Otolaryngology

• Fellowship in pediatric otolaryngology, Children’s Hospital Colorado• MSc, otolaryngology, McGill University• Residency in otolaryngology-head & neck surgery, McGill University• MD, CM, McGill University• Medical preparatory program, McGill University• College Diploma, Health Sciences,

Cégep de Sainte-Foy

WWW.CONNECTICUTCHILDRENS.ORG