Focus on Pediatrics Summer 2016 by Prisma Health

Telemedicine Opens Doors to Better Care Girls on the RunÂŽ Celebrates 10 Years Expanded Infusion Center Earns Rave Reviews

Vol. 28.2 Summer 2016

on Pediatrics

Ask the Faculty: Opioid Use

Bradshaw Institute Broadens Approach to Child Health

Focus on Pediatrics is published quarterly by Children’s Hospital of Greenville Health System. Medical Editor Joseph L. Maurer, MD Managing Editor Lark Reynolds

FROM THE MEDICAL DIRECTOR

GHS Photographer AV Services Art Director GHS Creative Services Editorial Board Linda Baumbach, CAP Nichole Bryant, MD Sally Cade Kristi Coker, MSN, MHA, RN Jeanine Halva-Neubauer Jennifer Hudson, MD Emily Hughes Crissy Maynard, FAHP, CFRE Eric Nash Terri Negron, MN, RN Janine Sally, MS, CCC-SLP Robert Saul, MD Kerry Sease, MD, MPH If you would like your name added to or removed from our mailing list or have any comments, questions or suggestions, please send the appropriate information to: Marketing Services Greenville Health System 300 E. McBee Ave. Suite 200 Greenville, SC 29601 (864) 797-7544 The information contained in the Focus is for educational purposes only—it should not take the place of medical advice or diagnoses made by healthcare professionals. All facilities and grounds of Greenville Health System are tobacco free. “Greenville Health System” and GHS symbol design are trademarks of Greenville Health System. © 2016 Greenville Health System 16-0531

Pediatrician Burnout Recently, Wendell James, MD, chair of Anesthesia, and David Williams, MD, chair of Radiology, held focus groups with GHS primary care physicians. The pair reported that burnout is occurring in many of our frontline physicians. Surely, I thought, not in the Department of Pediatrics, where we always are having fun. Wrong, they said. Burnout can be characterized many ways but usually includes loss of enthusiasm for work, increased cynicism and low sense of personal accomplishment. Every few years, Medscape (a digital medical news publication) tries to gauge our psychological well-being by surveying thousands of physicians. Its 2016 report found that pediatricians suffered a burnout rate of 53%—up from 36% just a few years ago! Only internal medicine, family medicine, critical care and emergency medicine were higher, but just by 2 percentage points. Top dissatisﬁers in the Medscape pediatric report were MOC requirements, too many bureaucratic tasks, too many work hours, too little income and increased computerization. Feedback from our own focus groups mirrored the national response: loss of autotomy, Epic challenges and the need to complete charts at home, too little pay, and a poor work-life balance. Dike Drummond, MD, a Mayo-trained family medicine physician-turned-coach who spoke to our medical staff several years ago, sees

burnout as entirely preventable. First, he says, “don’t quit your job.” Instead, look for the parts of it that give you joy, and focus more on those. Our organization can help as well. Because we all can relate in some degree to these dissatisﬁers, we need a plan to overcome them. George Haddad, MD, pediatric vice chair for Clinical Services, along with R. Austin Raunikar, MD, and Carley Howard Draddy, MD, senior medical directors for Specialty and Primary Care Pediatrics, respectively, soon will form a representative group of pediatricians to address how we at Children’s Hospital can enhance work satisfaction. If you want to be part of this group, please email me at wschmidt@ghs.org. I chose pediatrics as a career because it was the medical school rotation where I had the most fun, and I want it to stay that way. Let’s put more fun back in pediatrics!

William F. Schmidt III, MD, PhD

CONTENTS

Bradshaw Institute Tackles Community Health 2 Funded by the largest gift in GHS history, the new Bradshaw Institute aims to improve health for all Upstate children.

Telemedicine Increases the Reach of Medical Expertise 8 Technology is enabling Children’s Hospital physicians to provide services in places such expertise often is not readily available.

Girls on the Run® Celebrates 10 Years

This program has been empowering young girls in the Upstate community for a decade.

Pediatric Infusion Center 28 Increased access, pediatric focus make expanded infusion center a hit for families.

Departments What’s New 7 Inpatient Child Psychologist, Ukulele Therapy for Patients with Cancer, Bicycle Helmet Initiative

Medical Staff Spotlight 11 Meet Our New Physicians

Academic News 13 Congratulations to Graduating Residents; Welcome New Residents!

CME 16 What to Know About the Zika Virus

Quality Counts 19 The Link Between Quality and Finance

Celebrations 20 Accreditation and Philanthropic News

Case Study 22 Hospital Child with Acute Respiratory Changes

Clinical Research 25 Pediatric Endocrinology Studies

Ask the Faculty 30 Protecting Against Opioid Abuse

On the cover: William Bradshaw and wife Annette facilitated the creation of the Bradshaw Institute for Community Child Health & Advocacy with the largest gift ever given to Greenville Health System. The Bradshaw Institute will expand and focus on programs that existed under GHS Children’s Hospital’s Division of Children’s Advocacy.

28 To access this publication online, go to www.ghs.org/publications.

LEAD STORY Children’s Hospital of Greenville Health System (GHS) announces the system’s largest gift ever to form the Bradshaw Institute for Community Child Health & Advocacy.

Bradshaw Institute Paves the Way to Better Health As the nation shifts toward population health and keeping communities healthy, GHS Children’s Hospital has launched the Bradshaw Institute for Community Child Health & Advocacy. The Bradshaw Institute—an expansion and strategic focusing of Children’s Hospital’s Division of Children’s Advocacy—hopes to create optimal health for all children it serves. “We know that the advocacy services we have been providing are good and that they work,” said Linda Brees, the Bradshaw Institute’s executive director. “We’ve prevented death and injury. We’ve connected children and their families to communitybased services for developmental and behavioral concerns. We’ve done training across the state on mandated reporter training and child abuse detection.” She continued, “Moving forward, all of that work now is very focused and outcome driven. We’ll be tracking and measuring to get a better idea of the impact our programs are having.” As Bradshaw Institute staff gain a better idea of which programs are most effective, they will pass that information along to GHS pediatric practices to better equip them to serve the needs of their patients—both medical and social.

A ceremony held June 1 honored William and Annette Bradshaw (top photo) and their family for their ﬁnancial gift that facilitated the formation of the Bradshaw Institute for Community Child Health & Advocacy. William Schmidt III, MD, PhD (left), medical director of GHS Children’s Hospital, and President and CEO Mike Riordan (right), among others, spoke at the event.

“The Bradshaw Institute serves as a bridge between clinical practice and academics and research,” stated Kerry Sease, MD, MPH, senior medical director for Academics, and the Bradshaw Institute’s medical director. “We’re taking a closer look at what our community’s needs are, then will develop strategies using the best evidence that’s out there and take those back to the practices.” Several of the Bradshaw Institute’s programs likely sound familiar. Child Abuse Prevention, School Health Promotion, Help Me Grow SC and Safe Kids™ Upstate all existed under Children’s Advocacy. But now they are organized, along with additional initiatives, into four clusters—Prevention, Education, Healthy Child Development and Community Pediatrics.

The newest area of emphasis is Community Pediatrics, where much of the tie-in to clinical practices will occur. Objectives include exploring the use of medical-legal partnerships to improve health management, increasing access to medical care in underserved areas, identifying key health issues in the community and increasing access to camp experiences for children with conditions such as asthma, diabetes and cancer.

Caring for Kids at School One way the Bradshaw Institute will reach underserved communities is through school-based health centers. These centers are set up in four strategically selected middle schools, with plans to add a ﬁfth by summer’s end. A GHS nurse and nurse practitioner (NP) visit each clinic on speciﬁc days weekly to see children with health concerns. On days the nurse is not on-site, she can be reached remotely via telemedicine—a video software application through which the off-site NP can partner with the school nurse to conduct a physical examination using plug-ins such as an otoscope.

“School-based health centers are increasing access to care for communities where it may be challenging for parents to otherwise obtain medical care for their child,” Dr. Sease explained. “It’s helping us keep parents and children where they belong—at work and at school.” Dr. Sease said the centers also enable the NP to gain perspective on social factors that inﬂuence a child’s health, and she connects the child and family to appropriate community resources. “We know those factors exist, and we know the effect they have on a child’s long-term health,” she noted. “By being where kids are and identifying some of those stressors, we can get services for them earlier.” Community Pediatrics also will conduct pediatric population health management, which involves researching and mapping

Who Is the Bradshaw Family? At age 29, William Bradshaw and his wife, Annette, sold their small home and put their entire savings into a small CadillacOldsmobile dealership in Greer. Over the next 35 years, that one dealership expanded to four dealerships in Greenville and Greer with 383 employees and seven car lines. After the creation of Safe Kids™ Upstate, led by Children’s Hospital of Greenville Health System (GHS), the Bradshaws hosted a car seat inspection event at one of their dealerships. Thus was born the special relationship between Bradshaw Automotive and Safe Kids Upstate.

The event drew so much interest from the community that the family repeated it at other dealerships, and Mr. Bradshaw made a $5,000 gift to establish the Upstate’s ﬁrst permanent car seat inspection station at the Greer Fire Department. In 2006, the family gave Safe Kids Upstate a gift of more than $500,000, the largest gift ever received by any Safe Kids coalition member worldwide! That gift helped establish eight permanent car seat inspection stations in the Upstate and increased the staff size and reach of Safe Kids Upstate to include Pickens and Oconee counties. Since that time, the Bradshaw family has invested more than $1 million to ensure the sustainability of Safe Kids Upstate. In 2015, the family was recognized with the Safe Kids Worldwide Super Hero Award at the organization’s conference in Washington, D.C. William and Annette’s children have grown to become supporters of Children’s Hospital, too. The Bradshaws’ spirit of helping children and families in need now continues with the creation of the Bradshaw Institute for Community Child Health & Advocacy—the largest gift ever made to GHS! This investment will help create a safer and healthier community for our children, and it will provide a model program other communities can replicate.

Three generations of the Bradshaw family were present at the Bradshaw Institute’s announcement ceremony in June.

For instance, do children who attend Children’s Hospital camps take more responsibility over their own care? “We’ll be able to look at whether the independence these children experience in that camp setting translates into more ownership over their condition and their care,” he explained. “Do they end up having better outcomes?”

Connecting Offices with Solutions How do these initiatives and resources impact physician practices? One way is by taking up issues based on input from the practices. An executive advisory committee that includes representation from divisions across Children’s Hospital and primary care practices will help identify pressing community needs. “Next, we will develop strategies using the best evidence that’s out there,” Dr. Sease said. “What are those best practices that we can look at to tackle this issue? Then, we will devise strategies and take those to the practices.” As an example, a practice might reach out about how to add dental varnish to their protocols. The Bradshaw Institute is behind initiatives such as school-based health centers (top) in four upstate middle schools and the Hospital School Program (bottom).

health issues in the community to determine healthcare “hot spots” and how to improve those issues. For instance, Dr. Sease stated, if research uncovers that a pocket of children from a particular community are being treated for asthma, that information provides a strategic direction for targeted intervention that can have a direct impact on child health.

Valuable Research Opportunities While different divisions within Children’s Hospital already provide camp experiences for speciﬁc patient groups, those offerings now are centralized under Community Pediatrics. In addition to eliminating redundancy and improving the coordination of those camp offerings, this centralization makes it easier to evaluate the impact such experiences have on patients. Desmond Kelly, MD, vice chair of Academics and Community Affairs at GHS, will spearhead the research and evaluation of institute initiatives. While the programs are widely viewed as beneﬁcial, without the research there’s no evidence that the initiatives are actually improving the health of populations. “As we move to population health and as part of the vision of GHS to transform health care, we’re looking at innovative models for health service delivery, and there are so many opportunities to study and compare the effectiveness of different models of care,” Dr. Kelly said. “Having the infrastructure of the Bradshaw Institute will enable us to carry out that critical research.” 4

“We know that painting dental varnish on kids’ teeth prevents cavities,” Dr. Sease pointed out. “How do we help practices that see a large population of Medicaid, where those kids are at risk for dental caries, institute this protocol? I can take anything that I know from my experience at the Center for Pediatric Medicine; I can reach out to colleagues across the state to see where there’s been success; and then I can take a program to the practices.” The follow-up involves studying that program and determining if it is having a positive impact on community health.

Community Partnerships Seizure of a methamphetamine lab in the community is ﬁrst and foremost a law enforcement issue. But in cases where children are present in the home, a critical healthcare aspect also is involved. From 1999-2004, the reported number of children present at seized methamphetamine labs across the U.S. increased dramatically, from 950 to 3,000. About 55 percent of children removed from home-based meth labs test positive for toxic levels of chemicals in their bodies. In addition, because of the chemical effects of meth on adults in the home, such children are at an increased risk for neglect and physical and sexual abuse. To ensure such children receive the resources they need upon being removed from these situations—including appropriate health care—the national Drug Endangered Children (DEC)

task force was created in the early 2000s. Michelle Greco, BSN, RNC-MNN, CCE, serves as lead for the Greenville Alliance DEC task force as part of her role as manager of Child Abuse Prevention for the Bradshaw Institute. She works with deputies from the Greenville County Sheriff’s Office and other local child welfare agencies.

“Reaching children plays such an important role in transforming health care for generations.”

As part of her job, she may be called to the scene of a meth lab raid where it’s suspected that children are involved. She sees ﬁrsthand the deplorable condition many of these children live in and gains insight into what medical needs they may have. She then can communicate those insights to the personnel providing medical care to the children and ensure that no vital information goes unnoticed. The DEC task force is just one of many community partnerships with the Bradshaw Institute.

– Linda Brees, Bradshaw Institute executive director

“We see the Bradshaw Institute as being a hub,” Dr. Sease said. “Lots of other individuals and organizations in our community and state share our vision of improving the total health of children. Through partnerships with these organizations, we can reduce the number of children slipping through the cracks and provide better overall care to more children.”

The Next Generation of Caregivers In addition to improving child and community health, the institute aims to equip future generations of physicians and other caregivers to care for the whole child through relationships with USC School of Medicine Greenville, Clemson University, Furman University and others.

Children’s Hospital’s various camp programs for children with special needs now will be under the domain of the Bradshaw Institute, enabling targeted research on outcomes in these children.

“The Bradshaw Institute is a great resource for training and workforce development,” said Dr. Kelly. “Pediatric residents are having a much richer training experience in advocacy and all those components of addressing the social and environmental factors of health, as are social work interns, nursing students and those preparing for other community health disciplines.” In the meantime, the Bradshaw Institute places Children’s Hospital on the leading edge of the movement toward pediatric population health. While the institute may be based on existing programs and initiatives at Children’s Hospital, it focuses those initiatives in a strategic way to optimize the health of both children and families in the Upstate. “Before, children’s advocacy was a nice thing to do, and now it’s a critical thing to do,” emphasized Brees. “It was people doing great things for kids—now it’s a very strategic, positioned institute that will address this whole transition to population health.” She continued, “Reaching children plays such an important role in transforming health care for generations. By starting early, helping them develop good habits and get connected to a medical home, you can inﬂuence not only children’s health, but also family health and choices parents make about health care.”

The Bradshaw Institute will include Safe Kids Upstate’s many initiatives to prevent accidental childhood injury and death, such as car seat inspection stations (top) and life jacket and bicycle helmet-ﬁtting events (bottom).

A Little Help from Our Friends The Bradshaw Institute for Community Child Health & Advocacy relies on more than 90 community partners throughout the Upstate to achieve its vision of creating optimal health for all children it serves. Below is a small sample of these partners and how the Bradshaw Institute works with them. Center for Developmental Services: Members of the Bradshaw Institute’s leadership team serve on the Partnership Council of CDS, which is a co-location of agencies serving children with disabilities and their families.

Safe Kids Upstate staff members pose with Reedy Rip-it and members of the Greenville Drive staff at Safe Kids at the Drive night.

A Child’s Haven: Bradshaw Institute staff members serve on the advisory board of this child development center, which offers therapeutic intervention and prevention services for children with developmental delays. Children’s Trust of S.C.: Children’s Trust is the lead organization for Safe Kids of South Carolina and the state lead for the Maternal Infant & Early Childhood Home Visiting Program, which provides funding for Help Me Grow SC and helps develop the Common Agenda for Children in S.C. Greenville Drive: Greenville’s minor-league baseball team works with the Bradshaw Institute on workforce development and Safe Schools initiatives. Greenville First Steps: Bradshaw Institute members serve on the advisory board of this organization that is our state’s comprehensive early childhood education initiative and exists to ensure that children are ready for school success. First Steps provides funding for the institute’s Cribs for Kids program. Furman University: Bradshaw Institute executive director Linda Brees serves on the Furman Institutional Review Board. Institute for Child Success: Bradshaw Institute executive director Linda Brees is board chair. The group is dedicated to research and policy integration to achieve success for young children. Children’s Hospital also sponsors many organization activities, including the Yearly Research Symposium. Pendleton Place: Help Me Grow SC staff work with the Family Assessment Center team at Pendleton Place to provide developmental screening and care coordination for children entering foster care. School districts of Greenville, Oconee and Pickens counties: The Bradshaw Institute provides safety education, training and support to all 1,200 safety patrols in these three districts.

In fall of 2015, The Children’s Museum of the Upstate hosted the Buddy’s Safety Town exhibit to educate children and families about how to stay safe at home, at school, in the water, in cars and on bikes.

S.C. Children’s Hospital Collaborative: This collaborative brings together the leadership of the state’s four children’s hospitals in a variety of advocacy, development and quality improvement activities. S.C. Department of Health and Environmental Control and S.C. Department of Social Services Early Care and Education Division: These two state government entities have service contracts with Help Me Grow SC. The Children’s Museum of the Upstate: Children’s Hospital partners with the museum on a healthcare-themed exhibit and recently facilitated the museum’s Buddy’s Safety Town Exhibit. United Way of Greenville County: This agency funds On Track Greenville, which provides monies for the Bradshaw Institute’s school-based health centers as well as Help Me Grow SC. In addition, GHS Children’s Hospital partnered with the United Way to create the Institute for Child Success.

WHAT’S NEW? Children’s Hospital of Greenville Health System (GHS) welcomes its ﬁrst full-time inpatient psychologist and begins a program to put ukuleles in the hands of patients with cancer.

Specialists Serve Columbia

Pediatric rheumatologist Lara Huber, MD (left), and Anne Smith, RN, prepare to travel to Columbia to serve patients at Palmetto Health for the day.

Children’s Hospital is sending specialists to Columbia for day visits to provide services in partnership with Palmetto Health. Children’s Hospital’s two rheumatologists are helping to ensure that children statewide have access to high-quality medical specialty services.

Inpatient Psychologist Arrives Julie S. Jones, PsyD, is the ﬁrst full-time inpatient clinical psychologist at GHS Children’s Hospital. She is a member of the Supportive Care Team, which also includes a physician, nurse practitioner, additional nurse, chaplain and two child life specialists. To obtain her services, consult the Supportive Care Team.

Ukulele Kids Club Ukulele Kids Club, a national organization that donates ukuleles to music therapy programs at children’s hospitals, has partnered with the GHS Cancer Institute to make ukuleles and instruction on how to play them available to pediatric patients with cancer. The program, offered through a music therapist at GHS’ Center for Integrative Oncology and Survivorship, began in September 2015. A therapist uses the ukuleles in music therapy groups to improve patients’ memory and concentration. The therapist also teaches each patient simple chords so that by the end of the session, the child can play a song. Ukuleles are given to patients to keep.

Helmet Use Has Rewards

Dr. Jones also provides outpatient services to these children and families following their discharge from the hospital.

This Is How I Roll is a new initiative aimed at increasing helmet use in children. Through Children’s Hospital’s new Bradshaw Institute for Community Child Health & Advocacy, local businesses and community members have teamed up to encourage and reward children who wear a helmet when biking. When children and their families ride to a community partner and wear their helmets inside, they can ask about “helmet rewards” and receive a free surprise for making the safe choice to don a helmet.

“When a psychologist is introduced as a member of a team such as the Supportive Care Team, there is much more acceptance than if a patient or family is told to see a psychologist,” Dr. Stroud stated. “And she’s very friendly and non-threatening—the kind of person people like to talk to.”

As Greenville County has become a more bicycle-friendly community, more people have taken to their bikes to exercise and get around. With more people using bikes, though, related injuries have increased. In the last six years, bicycle head and face traumas have increased 47 percent in the county.

Dr. Jones earned her master’s degree in clinical psychology from Eastern Kentucky University in Richmond. She completed a psychology residency and post-doctoral fellowship at Cincinnati Children’s Hospital. She earned her Doctor of Psychology degree from the Georgia School of Professional Psychology at Argosy University, where she majored in child psychology. She can be reached at jjones@ghs.org or (864) 884-5059.

Safe Kids™ Upstate, led by Children’s Hospital’s Bradshaw Institute, has been working with pediatric medical providers to ensure that children seen at GHS’ Center for Pediatric Medicine or the North Greenville Outpatient Center for a bicycle-related injury can be given a properly ﬁtting helmet. According to Safe Kids Worldwide, bike helmets reduce head injuries by 85 percent.

“We find that nearly all patients and families who benefit from the services of a psychologist also benefit from the services of the entire Supportive Care Team,” said medical director Cary Stroud, MD. Having the psychologist function as a member of the Supportive Care Team increases the receptiveness of patients and families.

FEATURE STORY

Telemedicine Initiatives Expand At Greenville Health System (GHS), Children’s Hospital’s school-based health centers are a key component of the system’s new Bradshaw Institute for Community Child Health & Advocacy. That’s because they increase access to health care for middle school students in underserved communities. The four (soon to be ﬁve) centers are a central showpiece in the hospital’s increasing number of telehealth initiatives. These initiatives make use of video technology to bring the expertise of physicians and specialists to places that often don’t have access

The school-based health center at Lakeview Middle School.

to such knowledge. In the case of school-based health centers, when school nurses determine that a child’s condition warrants a higher level of medical evaluation, they can access such care quickly, without the child having to leave school.

Centers are located at schools in highrisk communities that were chosen by United Way of Greenville and are part of an effort to reduce absenteeism. A nurse/nurse practitioner (NP) team visits each school a few days a week and is available remotely the other weekdays. If needed, school nurses also can access Kerry Sease, MD, MPH, senior medical director for Academics and the Bradshaw Institute’s medical director. “The majority of the kids we’ve seen, we sent back to class,” Dr. Sease said. “That’s our goal: getting kids back in their seats for learning. We’re increasing access to care and keeping parents and kids where they belong—at work and at school.” Carley Howard Draddy, MD, senior medical director for Primary Care Pediatrics, said the technology includes plug-ins that allow the NP to see just as much as she would if present for the evaluation. For instance, an otoscope attachment can be plugged into a USB port and held to the student’s ear. The NP then can see an image of the eardrum on the screen of her telemedicine device.

Holly Bryan, PNP, prepares to check the blood pressure of Braxton Wilson, a student at Berea Middle School, at the school-based health center there. Bryan can be consulted through telemedicine technology on days she’s not on-site.

“Some people feel like your diagnosis is going to be less reliable with telemedicine, but with some of these plug-ins like the otoscope, you potentially get a better view of the tympanic membrane—and a picture that you can attach to the medical record,” Dr. Howard stated. “If a different provider sees the child two days later, that person could know exactly what the tympanic membrane looked like two days before.”

Delivery Buddy Debuts While school-based health centers tend to make more frequent use of telemedicine technology for lower-acuity issues, another telehealth initiative does the opposite. Delivery Buddy provides immediate access to a neonatal nurse practitioner (NNP) at two upstate GHS hospitals where such personnel are not physically present on a regular basis. While the need may not arise often—Dr. Howard estimates that about 2 percent of a community hospital’s deliveries may involve life-threatening complications—when it does, it’s a critical situation. Staff members at the community hospital alert their on-call pediatrician at the same time as they initiate the Delivery Buddy consultation. So as the physician is moving in the direction of the hospital, an NNP at Greenville Memorial Hospital is logging in to the Delivery Buddy technology to provide care during the gap until the doctor arrives. “It’s a way for us to be there and help without having to have an NNP at every hospital,” noted Tyner Lollis, NNP, the lead nurse practitioner for Delivery Buddy. “It gives the community hospital that provider level of expertise while waiting for the physician.” The service began at GHS’ Laurens County Memorial Hospital in December 2015 and at Baptist Easley, of which GHS is part owner, in April 2016. Since then, each hospital has called in one consultation, and both have had positive outcomes. In each situation, part of the NNP’s role is to assess whether the newborn needs to be transported to Greenville Memorial Hospital (GMH). In one case, the baby stabilized and was able to stay at the community hospital. In the other, transport was needed.

Another benefit of Delivery Buddy is decreased transport time. In the consultation at Baptist Easley, Treasure Snyder, NNP, realized almost as soon as she saw the neonate—three weeks premature and weighing only 2.5 pounds—that he would need to be transported, so she quickly activated the transport team. “Normally, the referring hospital is so involved in the delivery room and the management of the baby that staff have to first stabilize that baby before anyone can leave the bedside to make the phone call to transfer,” Snyder said. “But in this case, as soon as I saw how small the baby was, I knew it was an immediate transfer. So while I was talking them through the resuscitative process, I also had activated the transport team.” Dr. Howard said Delivery Buddy can save 30 or more precious minutes when it comes to transporting the baby. “Rather than it being 20 minutes before the doctor arrives in the delivery room and another 15 minutes to assess the patient, and then make the call to the neonatologist, maybe now it’s five or 10 minutes before they’re starting to send the transport team,” she emphasized. And when the baby arrives at GMH, the NNPs are up to speed with the baby’s history because one of them has been involved in the process since the start. Snyder pointed out that all nursing staff at the community hospitals are trained in neonatal resuscitation, and respiratory therapists are immediately available there as well. “I’m there as a guide and a leader to help them, because they don’t see this on a day-to-day basis the way we do at GMH,” she said. “Community hospitals are proactive in getting moms with high-risk pregnancies transferred before delivery if at all possible, but in those cases where it’s not possible to put a mom in an ambulance to travel to GMH, we’re there to guide them and help them take care of those babies in the delivery room.” GHS was able to draw on the experiences of a similar, successful delivery room telehealth program at Randall Children’s Hospital at Legacy Emmanuel, located in Portland, Ore. A consultant from Portland visited Children’s Hospital as Delivery Buddy was being set up and provided insight and valuable information, Dr. Howard said.

“Delivery Buddy gives the community hospital that provider level of expertise while waiting for the physician.” – Tyner Lollis, NNP

Telemedicine vs. Travel Another telehealth initiative is a pilot study in the Division of Pediatric Gastroenterology. Jonathan Markowitz, MD, MSCE, is a regional expert on eosinophilic esophagitis (EoE), and his clinic attracts patients from around the Southeast. Many require frequent visits for symptom checks and counseling. The study will allow Dr. Markowitz to measure patient satisfaction with a telemedicine vs. in-person visit. He plans to enroll patients in South Carolina who travel more than 60 miles to Greenville for an appointment.

“These telemedicine visits could represent a considerable ﬁnancial savings, and I’m sure that translates into satisfaction as well,” Dr. Markowitz said. “Driving a total of eight to 10 hours for a 30-minute visit is not that efficient.” He continued, “Of course, a telemedicine visit limits some of the things we can do, because we can’t do an in-depth physical exam. But because a lot of the management we do with these patients is counseling, they’re a good population to look at.” Dr. Markowitz received the telehealth cart through a grant from the South Carolina Telehealth Alliance. His staff transformed a room that previously was used for patient infusions (see Page 28) into a telemedicine center to make the visits as professional as possible. Patients in the study will schedule their next follow-up visit as a telemedicine visit. Then, rather than drive for hours, patients can log on to the secure video app at their next appointment. In addition to the telemedicine visit, patients will ﬁll out a disease activity scale online. Dr. Markowitz hopes to develop broad uses for the telemedicine technology to improve care for various patient populations. Dr. Howard also sees numerous possibilities for telehealth technology going forward.

Telehealth equipment at the Division of Pediatric Gastroenterology will allow patients who live far from Greenville to have telemedicine checkups instead of having to travel for hours for a short in-person checkup.

“I think it has a huge role in the future, when we look at population health and taking care of people and best using our resources,” she said. “Not every patient needs an in-person visit. Health care is changing so quickly, and we’re looking for ways to provide high-quality care that best utilizes our resources.”

“These telemedicine visits could represent a considerable ﬁnancial savings, and I’m sure that translates into satisfaction as well. Driving a total of eight to 10 hours for a 30-minute visit is not that efficient.” – Jonathan Markowitz, MD, MSCE

MEDICAL STAFF SPOTLIGHT Childrenâ&#x20AC;&#x2122;s Hospital of Greenville Health System (GHS) welcomes several new physicians to the GHS Medical Staff.

Meet Our New Physicians General Pediatrics Anthony E. Delgado, MD, graduated from the F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md. He completed his Pediatrics residency at the National Capitol Consortium at Walter Reed Military Medical Center in Bethesda. Dr. Delgado has worked as head of the pediatrics departments at U.S. Naval Hospitals in Okinawa, Japan and Rota, Spain. He also served as chairman of the Department of Pediatrics and medical director of the Newborn Nursery at Naval Medical Center Portsmouth in Virginia. For the last four years, Dr. Delgado has been deployed as a general pediatrician in Djibouti, Africa, and in Latin American and the Caribbean. He is working at the Greenville Pediatric Health Center. He can be reached at (864) 262-3012. Nicholas O. Kelley, MD, graduated from Mercer University School of Medicine in Macon, Ga. He completed his Pediatrics residency at GHS. Dr. Kelley is working as a pediatrician with the Spartanburg Night Clinic and Spartanburg Pediatric Health Center. He can be reached at (864) 7072135. Mark B. Krom, DO, earned his medical degree from the Edward Via College of Osteopathic Medicine in Blacksburg, Va. He completed his Pediatrics residency at GHS. Dr. Krom is working as a pediatrician with the Center for Pediatric Medicine. He can be reached at (864) 220-7270.

Easter L. Pennington, MD, earned her medical degree from the University of Kentucky College of Medicine in Lexington. She completed her Pediatrics residency at GHS. Dr. Pennington is working as a pediatrician at the Center for Pediatric Medicine. She can be reached at (864) 220-7270. Teresa A.W. Williams, MD, earned her medical degree from the University of Alabama at Birmingham School of Medicine. She completed her residency training in Medicine-Pediatrics at GHS. Dr. Williams is working as a pediatrician at the Center for Pediatric Medicine and can be reached at (864) 220-7270.

Pediatric Endocrinology Melissa D. Garganta, MD, earned her medical degree from University of South Carolina School of Medicine Columbia. She completed her residency training in Pediatrics at GHS, where she served as chief resident the year after graduation. Dr. Garganta completed a fellowship in Pediatric Endocrinology at Vanderbilt University School of Medicine. Her research interests include glucose control during exercise in adolescents and hormone deďŹ ciencies in cancer survivors. Dr. Garganta can be reached at (864) 454-5100.

New Community Pediatrician We welcome the addition of Christina M. Martin, MD, to the GHS-owned practice of Christie Pediatrics. Dr. Martin can be reached at (864) 242-4840.

Dr. Buchanan Elected to Executive Committee Pediatric hospitalist April Buchanan, MD, FAAP, was elected to serve on the Executive Committee of the Council on Medical Student Education in Pediatrics. This national organization promotes exemplary teaching practices, advances innovation and scholarship in medical student education in pediatrics, and fosters the personal growth and professional success of its members. Dr. Buchanan also is an assistant dean of Clinical Clerkship Education and an associate professor of Pediatrics at the USC School of Medicine Greenville.

Dr. Saul Elected to American Pediatric Society Robert A. Saul, MD, FAAP, FACMG, was elected Active membership to the American Pediatric Society (APS) in January. Active membership in the APS is reserved for individuals in the U.S. and Canada who have distinguished themselves as child health leaders, teachers, scholars, policymakers and/or clinicians, and whose important contributions are recognized nationally or internationally.

Office Openings and Relocations Pediatric Associates–Simpsonville opened its doors July 5. Stephen E. Lookadoo Jr., MD; Kevin A. Springle, MD; and O. Perry Earle, MD, offer high-quality pediatric care at this new practice. All three physicians moved from other GHS pediatric practices—Drs. Lookadoo and Springle were previously with Christie Pediatric Group, and Dr. Earle was a pediatrician at The Children’s Clinic. The practice is located at 1409 W. Georgia Road, Suite A, in Simpsonville. The phone number is (864) 454-5062. Clemson-Seneca Pediatrics relocated its Seneca facility to 109 Omni Drive, Suite B, Seneca, 29672. The new location is on the main campus of GHS’ Oconee Memorial Hospital. The phone number remains the same: (864) 888-4222.

Cancer Center Renovations Following on the heels of renovations to the Haynsworth Day Hospital at GHS Children’s Hospital’s BI-LO Charities Children’s Cancer Center, the rest of the center has received a makeover, too. A new, vibrant color scheme was used for the waiting room and patient exam rooms. Each room is named for an animal, with a connecting positive character trait displayed along with a photo of the animal inside the room. Couches in the waiting room were re-upholstered and new chairs purchased for the waiting room and treatment rooms. A ﬁsh tank that had previously been visible only to patients in the day hospital now sits in a double-sided viewing area, visible in the hallway as well. A small statue of a lion with a child in the waiting room is similar to the one that will occupy the Children’s Garden at Greenville’s Cancer Survivors Park when it is completed. The miniature version was given to the cancer center by one of the staff members in memory of her mother, who died from cancer. “The renovations have really boosted everyone’s morale and made the staff feel very proud about our space,” said Cathy King, nursing supervisor at the center. “Kids love the theme rooms.” MTC Federal Credit Union donated a portable snack cart and has committed to keeping it stocked so that patients can enjoy complimentary snacks during long visits. The renovations cost about $5 million, with much of those funds coming from Clement’s Kindness Fund and other community donors.

ACADEMIC NEWS Children’s Hospital of Greenville Health System (GHS) congratulates all of our residents who graduated in May 2016 and welcomes 11 new Pediatric residents, ﬁve MedicinePediatrics residents and a new Developmental-Behavioral fellow.

Congratulations, Graduates! Pediatric Meagan Aiken, MD, began work in private practice at Kazoo Pediatrics of Tennova Harton Regional in Tullahoma, Tenn. Matthew Bradshaw, MD, has joined AnMed Health Pediatric Associates in Anderson, S.C. Lee Glenn, MD, has joined Children’s Medical Center in Greenville, S.C.

Dr. Aiken

Dr. Bradshaw

Dr. Glenn

Dr. Hayes

Dr. Kelley

Dr. Krom

Dr. McNemar

Dr. Moore

Dr. Norton

Dr. Pennington

Dr. Walroth

Dr. A. Burgess

Dr. S. Burgess

Dr. Dewald

Dr. Williams

Chad Hayes, MD, began work in private practice at Threshold Pediatrics in Charleston, S.C. Nicholas Kelley, MD, joined GHS’ Spartanburg Night Clinic and Spartanburg Pediatric Health Center, part of GHS. Mark Krom, DO, has joined GHS Children’s Hospital as co-chief pediatric resident and junior faculty member. Sarah McNemar, MD, began work in private practice at Parkside Pediatrics in Greenville, S.C. Hunter Moore, MD, began work in private practice at Parkside Pediatrics in Greenville, S.C. Mary Norton, MD, will take an extended maternity leave before determining her future plans. Easter Pennington, MD, has joined Children’s Hospital’s Center for Pediatric Medicine. Emily Walroth, MD, has joined Beaufort Jasper Hampton Comprehensive Health Services in Ridgeland, S.C.

Medicine-Pediatrics Andrew Burgess, MD, has joined GHS Pediatrics & Internal Medicine–Wade Hampton. Shannon Burgess, MD, has joined GHS Pediatrics & Internal Medicine–Wade Hampton. Elizabeth Dewald, MD, has joined GHS as a hospitalist and will practice at GHS Pediatrics & Internal Medicine–Wade Hampton. Teresa Williams, MD, has joined GHS Children’s Hospital as cochief pediatric resident and junior faculty member. 13

Welcome, New Residents! Pediatric Paolo Arce, MD: Medical University of South Carolina College of Medicine, Charleston, S.C. Richard â&#x20AC;&#x153;Tylerâ&#x20AC;? Barnes, MD: Mercer University School of Medicine, Macon, Ga. Kindal Dankovich, MD: University of South Carolina School of Medicine Greenville, Greenville, S.C.

Natalie Vajita, MD: Medical University of South Carolina School of Medicine, Charleston, S.C. Gretchen Vandiver, MD: University of South Alabama College of Medicine, Mobile, Ala. Nicole Wischmeyer, MD: Mercer University School of Medicine, Macon, Ga.

Medicine-Pediatrics Jennifer Davis, MD: University of South Carolina School of Medicine Greenville, Greenville, S.C.

Ranjan Banerjee, MD: University of North Carolina, Chapel Hill, School of Medicine, Chapel Hill, N.C.

Christopher Graves, MD: University of Alabama at Birmingham School of Medicine, Birmingham, Ala.

Luke Burton, MD: Brody School of Medicine, East Carolina University, Greenville, N.C.

Michelle Khawaja, MD: Medical University of South Carolina School of Medicine, Charleston, S.C.

Tien Nguyen, MD: Morsani College of Medicine, University of South Florida, Tampa, Fla.

Madison Merritt, MD: University of South Carolina School of Medicine Greenville, Greenville, S.C.

Walt Roberts, MD: Mercer University School of Medicine, Macon, Ga.

Rachel Reynolds, MD: Medical University of South Carolina School of Medicine, Charleston, S.C.

Kevin White, MD: University of North Carolina, Chapel Hill, School of Medicine, Chapel Hill, N.C.

Dr. Arce

Dr. Barnes

Dr. Dankovich

Dr. Davis

Dr. Graves

Dr. Merritt

Dr. Reynolds

Dr. Vajita

Dr. Vandiver

Dr. Wischmeyer

Dr. Banerjee

Dr. Burton

Dr. Nguyen

Dr. Roberts

Dr. White

Dr. Khawaja

DevelopmentalMatch Day for USC School of Behavioral Medicine Students Pediatrics Fellowship In March 2016, the inaugural graduating class of medical Fellowship graduate Caroline Buchanan, MD, has joined Greenwood Genetic Center in Greenville, S.C.

New DevelopmentalBehavioral Fellow Darla McCain, MD, has joined Children’s Hospital as a fellow with the Division of Developmental-Behavioral Pediatrics. She earned her medical degree from the McGovern Medical School at the University of Texas in Houston. Dr. McCain completed her Pediatrics residency at the University of North Carolina Hospitals in Chapel Hill.

Dr. Saul Co-authors Genetics Article Robert Saul, MD, FAAP, FACMG, medical director of General Pediatrics at GHS Children’s Hospital, recently published “Beyond the Genetic Diagnosis: Providing Parents What They Want to Know” in July 2016’s Pediatrics in Review. The articles stresses the importance of providing accurate, up-to-date information to parents following a prenatal or postnatal diagnosis of a genetic condition as outcomes can change significantly over time based on available social support, health care and services. Conditions discussed are Down syndrome, Trisomy 13/18, cystic fibrosis, Turner syndrome, Klinefelter syndrome, XXYY, spina bifida, Jacobsen syndrome, Williams syndrome, Fragile X syndrome, Cri-du-Chat syndrome, Wolf-Hirschhorn syndrome and 22q deletion syndrome. The article lists medically reviewed resources that clinicians and parents can use at the moment of diagnosis. It also provides tables listing myth vs. reality associated with different conditions and the evolution of outcomes (spanning 1970-2016) for people with Down syndrome.

students at University of South Carolina School of Medicine Greenville held their Match Day ceremony at the Peace Center in Greenville. Of the 49 graduating students, nine will pursue Pediatric residencies at programs in North and South Carolina, Florida, Arizona and Hawaii. Three students matched with Children’s Hospital’s Pediatric Residency Program.

Resident and Faculty Awards The following doctors and caregivers were recognized at Pediatric Residency Program graduation ceremonies: • Emily Walroth, MD: Pediatric Resident Teaching Award (voted on by ﬁrst- and second-year Pediatric residents) • Mark Krom, DO: Pediatric Resident Teaching Award (voted on by medical students); Miracle Maker Award (given by Pediatric faculty for extraordinary care, community service and furtherance of health education) • Matthew Grisham, MD, and Joshua Brownlee, MD: John P. Matthews Jr., MD, Outstanding Faculty Teaching Award (given by residents to a general pediatrician and to a subspecialist for superb teaching and enthusiasm for resident education) • Robert Siegler, MD: Paul V. Catalana, MD, Exemplary Character Award (given by the graduating class to a caregiver who exhibits the qualities of honesty, fairness, compassion, altruism and leadership by example) • Pediatric Intensive Care Unit: 2016 Division of the Year Award (chosen by Pediatric residents) • Sarah McNemar, MD: Margaret L. Wyatt, MD, Outstanding Grand Rounds Award • Matthew McGee, MD: Pediatric Resident Journal Club Award • Teresa Williams, MD: Medicine-Pediatrics Resident Achievement Award (chosen by Pediatric faculty for teaching and research skills and commitment to education) • Craig Anderson, MD: Inpatient Care Award (voted on by inpatient Pediatric faculty) • Megan Witrick, MD: Primary Care Award (for outstanding care in the outpatient setting as voted on by ambulatory Pediatric faculty) 15

CONTINUING MEDICAL EDUCATION

Zika: Newest Threat to Infants CME Credit Information To receive possible continuing medical education (CME) credit for this article, please complete the online Q&A that can be accessed on page 18. Both physicians and nurses are eligible to test for the credit. It is the policy of the GHS Continuing Medical Education Committee to ensure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored education activities. Article author Robin LaCroix, MD, has disclosed that she has no significant financial interest or relationship with any company that may be considered an actual or potential conflict of interest with this educational activity. The planning committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity. The CME committee have listed no duality of interest with regard to potential relevant financial relationships for the FOCUS enduring activity with the exception of Sandra Weber, MD (Committee Chair), Grant/ Research Support–Eli-Lilly, NIH, and Pfizer and William A. Coleman, MD (OB/GYN), Consultant–Merck. The Greenville Health System (GHS) designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Greenville Health System is accredited by the South Carolina Medical Association to provide continuing medical education for physicians.

Zika virus is a mosquito-born flavivirus that was first reported as a human pathogen in 1947. It was initially described as causing a mild, self-limited illness in Africa and Asia. The first large outbreak was recognized on Yap Island in Micronesia in 2007. The next large outbreak was in French Polynesia in 2013-2014. It is believed that the French Polynesia strain is the current strain that emerged in Brazil in May 2015. The epidemic as a congenital infection was recognized when analysis of birth data indicated a 20-fold increase in microcephaly. Zika virus is in the family of dengue, West Nile and yellow fever viruses. Clinically, it also may resemble Chikungunya. Only about 20% of adults and children who acquire the infection will experience a symptomatic infection. If they do have clinical symptoms, these may include muscle pain and headache, fever, rash, joint pain and non-purulent conjunctivitis. The rash is maculopapular and pruritic. Incubation period is 3-14 days after being bitten by an infected mosquito. There is no treatment for the infection, and most cases are mild and

last from several days to a week. Hospitalization is rare and the most common adult complication following infection is GuillainBarré syndrome. However, for pregnant women who become infected with the virus, it appears there is a neurotrophism in fetuses resulting in CNS and ocular abnormalities. The virus has been found to infect neural progenitor cells and produce cell death and abnormal growth, which explains the brain malformations and microcephaly. The virus has been found in fetal brain tissue, further supporting Zika as the etiology of the pathologic changes. The speciﬁc risk of brain defects based on gestational age at the time of infection still is being studied. A recent article published in The Lancet evaluated 600 infants in Brazil thought to be infected by the Zika virus. One concerning ﬁnding from this study was that women infected in the third trimester of pregnancy who presented with a rash had infants with brain abnormalities despite normal-sized heads.

Virus Transmission The virus is transmitted from a number of mosquito species. Aedes aegyptus is thought to be a major vector, but transmission also can occur from Aedes albopictus. In the U.S., the natural range for Aedes aegyptus is the southern part of the country and as far north as Connecticut, Ohio, southern Indiana, Kansas and Missouri. The Aedes albopictus has a wider territory extending to the Northeast and up to the Great Lakes. Control of the Aedes aegypti species is difficult because they can reproduce in extremely small amounts of water and the eggs are extremely hardy to drying. This mosquito species also is a daytime feeder. The S.C. Department of Health and Environmental Control (DHEC) reports very low populations of Aedes aegyptus in South Carolina, but a larger population of Aedes albopictus. The virus is capable of transmitting via semen and blood transfusion as well. It can be found in a number of other body ﬂuids, including breastmilk, saliva, cerebrospinal ﬂuid and urine. The widespread nature of the viremia has led the Centers for Disease Control and Prevention (CDC) to issue recommendations around sexual practices in an effort to prevent the fetus from being exposed. Women who have Zika virus disease should wait at least eight weeks after symptom

onset to attempt conception, and men with Zika virus disease should wait at least six months after symptom onset to attempt conception. Women and men with possible exposure to the Zika virus but without clinical illness consistent with Zika virus disease should wait at least eight weeks after exposure to attempt conception. Despite the transmissibility of the virus in human-to-human body ﬂuids, routinely used disinfectants such as alcohol, UV, heat sterilization and other inactivation procedures are sufficient to inactivate the Zika virus.

Congenital Aspects The Brazilian outbreak brought the congenital manifestations of maternal infection to the forefront. The description of microcephaly, brain abnormalities, intracranial calciﬁcations, ocular abnormalities and hearing deﬁcits all have been linked to congenital Zika infection. The CDC has a number of recommendations around additional evaluation, including neurologic evaluation and a complete physical exam looking for dysmorphic features, hepatosplenomegaly, rashes or skin lesions. Retinal exam before discharge or within 1 month after birth is recommended as is a hearing evaluation prior to discharge or within 1 month of birth. The infants often are described as having very redundant skin on the back of the neck and a head circumference less than the 3rd percentile. As new epidemiologic studies are published, additional recommendations for infant evaluation are expected.

A rash is one of the known symptoms of Zika; therefore healthcare providers should ask any patients who present with a rash about their travel history.

Zika Questions? Call 1-800-CDC-INFO (232-4636): 8 a.m.-11 p.m. weekdays, 9 a.m.-5 p.m. weekends. Diagnosis Diagnosis of Zika includes both molecular and serologic testing. Current recommendations include serum testing within the first week of illness looking for virus RNA. If there has been more than a week of clinical illness, urine RNA testing up to two weeks may be positive. IgM antibodies to Zika may be present in serum and spinal fluid. These antibodies develop during the first week of illness and persist for approximately 12 weeks following infection. Because extensive cross-reactivity occurs in flavivirus serologic assays, a positive IgM requires additional testing to distinguish Zika virus from other flavivirus infections.

Safeguards As of June 2016, Zika had been reported in South America, Central America, Mexico and the islands off the coast of Central America and South America, including Puerto Rico and the U.S. Virgin Islands. Because of extensive transmission locally and the risk for bloodborne transmission, Puerto Rico began blood donor screening in April 2016. This screening used a newly developed test and has been performed on all locally donated blood in Puerto Rico and the U.S. Virgin Islands, along with donations from border areas such as Texas and South Florida. In the continental United States, blood donation centers have excluded travelers who have been in endemic countries from donating for a period of time after returning to the U.S.

U.S. Endemic Transmission In mid-June, the ﬁrst cases of domestic transmission were reported from Miami. The Florida Department of Health has initiated mosquito control in the area of transmission. On Aug. 1, the CDC issued a warning for pregnant women to avoid non-essential travel to areas in Florida identiﬁed as areas of possible transmission. This warning also cautions men and women who have traveled to these areas to defer pregnancy for a time. For pregnant women and their partners who have traveled to these areas, precautions should be taken to avoid infection from sexual transmission for the remainder of the pregnancy. Zika now is a reportable condition to state health authorities, and a registry has been created in the U.S. to better understand 18

the infant effects of perinatal infection. A large multinational study also is underway to examine the effects of Zika in 10,000 pregnant women in South America. The U.S. Food and Drug Administration in early June 2016 approved a fast-track evaluation of a vaccine for Zika. Phase 1 clinical trials evaluating the safety of the vaccine began by July. If it is felt to be safe after the Phase 1 trials, Phase 2 efficacy trials will begin in countries with a high prevalence of circulating virus. Information regarding management and diagnoses for Zika infection continues to change on a weekly basis. Given the need to track and understand the epidemiology, pediatricians are urged to contact the CDC Emergency Operations Center for the most up-to-date recommendations on testing of infants suspected to have congenital Zika infection. The phone number to reach the CDC Emergency Operations Center is (770) 4887100. Additionally, South Carolina has listed suspected Zika infection as a reportable condition to DHEC. In the Upstate, call DHEC at (864) 282–4373 for help in obtaining the appropriate testing. References Consulted •

cdc.gov

•

Driggers RW, Ho C-Y, Korhonen EM, Kuivanen S, Jääskeläinen AJ, Smura T, et al. Zika virus infection with prolonged maternal viremia and fetal brain abnormalities. N Engl J Med. 2016;374:2142-2151.

•

Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika virus. N Engl J Med. 2016;374:1552-1563.

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Mlakar J, Korva M, Tull N, Popović Mara, Poljšak-Prijatelj M, Mraz J, et al. Zika virus associated with microcephaly. N Engl J Med. 2016;374:951-958.

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Fauci AS, Morens DM. Zika virus in the Americas—yet another arbovirus threat. N Engl J Med. 2016;374:601-604.

Other Resources •

How pregnant women can protect themselves against Zika: cdc.gov/zika/ pregnancy/protect-yourself

•

For a list of endemic areas: cdc.gov/zika/geo

Article author Robin LaCroix, MD, is a Pediatric Infectious Disease physician at Children’s Hospital of Greenville Health System.

CME Questions Available Online As a convenience for our audience and to conserve resources, Focus on Pediatrics has transitioned to an online format for the Q&A portion of CME articles. Here is a link and a QR code you can use to access the CME questions online. http://www.ghs.org/PediatricsElectronic

GHS Children’s Hospital Physician Directory For admission to Children’s Hospital: (864) 455-0000

Phone William F. Schmidt III, MD, PhD 455-8401 Medical Director; Chairman, Department of Pediatrics

Fax 455-3884

Adolescent Bariatric Surgery Eric S. Bour, MD 676-1072 676-0729 Adolescent Medicine 220-7270 241-9211 Sarah B.G. Hinton, MD Allergy, Immunology and Asthma James L. Kuhlen Jr., MD 675-5000 675-5005 John M. Pulcini, MD 675-5000 675-5005 Ambulatory Pediatrics/Center for Pediatric Medicine (Medicaid) J. Blakely Amati, MD 220-7270 241-9211 Jessica P. Boyd, MD 220-7270 241-9211 Elizabeth W. Burton, MD 220-7270 241-9211 Janelle E. Godlewski, MD 220-7270 241-9211 Jill D. Golden, MD 220-7270 241-9211 Lochrane Grant, MD 220-7270 241-9211 Matthew P. Grisham, MD 220-7270 241-9211 Sarah B.G. Hinton, MD 220-7270 241-9211 Mark B. Krom, DO 220-7270 241-9211 Dolores P. Mendelow, MD 220-7270 241-9211 Sara E. Ryder, MD 220-7270 241-9211 Robert A. Saul, MD 220-7270 241-9211 Kerry K. Sease, MD, MPH 220-7270 241-9211 Cady F. Williams, MD 220-7270 241-9211 Teresa A.W. Williams, MD 220-7270 241-9211 Angela M. Young, MD 220-7270 241-9211 Anesthesiology Carlos L. Bracale, MD 522-3700 522-3705 Michael G. Danekas, MD 522-3700 522-3705 Lauren H. Doar, MD 522-3700 522-3705 John P. Kim, MD 522-3700 522-3705 Jake Freely, MD 522-3700 522-3705 Richard F. Knox, MD 522-3700 522-3705 Laura H. Leduc, MD 522-3700 522-3705 Steven W. Samoya, MD 522-3700 522-3705 Matthew R. Vana, MD 522-3700 522-3705 Randall D. Wilhoit III, MD 522-3700 522-3705 Bradshaw Institute for Community Child Health & Advocacy Kerry K. Sease, MD, MPH 454-1100 454-1114 Cardiology Benjamin S. Horne III, MD 454-5120 241-9202 Jon F. Lucas, MD 454-5120 241-9202 David G. Malpass, MD 454-5120 241-9202 Manisha S. Patel, MD 454-5120 241-9202 R. Austin Raunikar, MD 454-5120 241-9202 Child Advocacy Medical Program Mary-Fran R. Crosswell, MD 335-5288 331-0565 Nancy A. Henderson, MD 335-5288 331-0565 Critical Care Michael G. Avant, MD 455-7146 455-5380 Eric L. Berning, MD 455-7146 455-5380

Phone Fax Christina M. Goben, MD 455-7146 455-5380 Darryl R. Gwyn, MD 455-7146 455-5380 Robert S. Seigler, MD 455-7146 455-5380 Developmental-Behavioral Peds/Gardner Center for Developing Minds James H. Beard Jr., MD 454-5115 241-9205 Tara A. Cancellaro, MD 454-5115 241-9205 Gerald J. Ferlauto, MD 454-5115 241-9205 Desmond P. Kelly, MD 454-5115 241-9205 Darla H. McCain, MD 454-5115 241-9205 Nancy R. Powers, MD 454-5115 241-9205 Victoria L. Sheppard-LaBrecque, MD 454-5115 241-9205 John E. Williams, MD 454-5115 241-9205 Emergency Medicine 455-6016 455-6199 Elizabeth L. Foxworth, MD Jacqueline J. Granger, MD 455-6016 455-6199 Alison M. Jones, MD 455-6016 455-6199 Patrick J. Maloney, MD 455-6016 455-6199 Matthew B. Neal, MD 455-6016 455-6199 Kevin A. Polley, MD 455-6016 455-6199 Jeremiah D. Smith, MD 455-6016 455-6199 John D. Wilson Jr., MD 455-6016 455-6199 Endocrinology James A. Amrhein, MD 454-5100 241-9238 Elaine A. Apperson, MD 454-5100 241-9238 Melissa D. Garganta, MD 454-5100 241-9238 Bryce A. Nelson, MD, PhD 454-5100 241-9238 Ferlauto Center for Complex Pediatric Care W. Kent Jones, MD 220-7270 241-9211 Cady F. Williams, MD 220-7270 241-9211 Gastroenterology Liz D. Dancel, MD 454-5125 241-9201 Michael J. Dougherty, DO 454-5125 241-9201 Emily N. Kevan, MD 454-5125 241-9201 Jonathan E. Markowitz, MD, MSCE 454-5125 241-9201 Colston F. McEvoy, MD 454-5125 241-9201 Genetics David B. Everman, MD 250-7944 250-9582 R. Curtis Rogers, MD 250-7944 250-9582 Gynecology Melisa M. Holmes, MD 455-1600 455-2805 Benjie B. Mills, MD 455-1600 455-2805 Hematology/Oncology / BI-LO Charities Children’s Cancer Center Nichole L. Bryant, MD 455-8898 241-9237 455-8898 241-9237 Rebecca P. Cook, MD Cristina E. Fernandes, MD 455-8898 241-9237 Leslie E. Gilbert, MD, MSCI 455-8898 241-9237 Aniket Saha, MD, MSCI, MS 455-8898 241-9237 William F. Schmidt III, MD, PhD 455-8898 241-9237 Infectious Disease Joshua W. Brownlee, MD 454-5130 241-9202 Sue J. Jue, MD 454-5130 241-9202 Robin N. LaCroix, MD 454-5130 241-9202 Continued on back

Phone Inpatient Pediatrics Greenville April O. Buchanan, MD 455-8401 Gretchen A. Coady, MD 455-4411 Karen Eastburn, DO, MS 455-8401 Jeffrey A. Gerac, MD 455-4411 Matthew P. Grisham, MD 455-8401 Amanda G. Hartke, MD, PhD 455-8401 Russ C. Kolarik, MD 455-7844 Elizabeth S. Tyson, MD 455-8401 Greer Matthew N. Hindman, MD 455-4411 Anderson Callie C. Barnwell, MD 454-5612 Sara M. Clark, MD 454-5612 Carley M. Howard Draddy, MD 454-5612 Ann Marie Patterson, MD 454-5612 Allison B. Ranck, MD 454-5612 Senthuran Ravindran, MD 454-5612 Silvia Y. Rho, MD 454-5612 Elizabeth A. Shirley, MD 454-5612 Miranda L. Worster, MD 454-5612 Minor Care Children’s Hospital After-hours Care (Greenville) Staffed by current GHS pediatricians 271-3681 Children’s Hospital Spartanburg Night Clinic George C. Haddad Jr., MD 804-6998 Charles R. Hatcher III, MD 804-6998 Nicholas O. Kelley, MD 804-6998 Neonatology/Bryan Neonatal Intensive Care Unit India C. Chandler, MD 455-7939 Benton E. Cofer, MD 455-7939 Nicole A. Cothran, MD 455-7939 J. Thomas Cox, MD 455-7939 R. Catrinel Marinescu, MD 455-7939 Bryan L. Ohning, MD, PhD 455-7939 Jeffrey M. Ruggieri, MD 455-7939 Michael S. Stewart, MD 455-7939 M. Whitson Walker, MD, MS 455-7939 Nephrology & Hypertension Franklin G. Boineau, MD 454-5105 T. Matthew Eison, MD 454-5105 Scott W. Walters, MD 454-5105 Neurology Emily T. Foster, MD 454-5110 Addie S. Hunnicutt, MD 454-5110 Augusto Morales, MD 454-5110 William C. Taft, MD, PhD 454-5110 Neurosurgery E. Christopher Troup, MD 797-7440 Newborn Services Jennifer A. Hudson, MD 455-3512 Rebecca P. Wright, MD 455-3512 Ophthalmology Alison S. Smith, MD 454-5540 Janette E. White, MD 454-5540

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ghschildrens.org 16-0531 Revised 8/16

QUALITY COUNTS

Quality-related Revenue: The New Reality Financial incentives or penalties that are tied to quality improvement are the new reality. Molina Healthcare of South Carolina, a major provider of managed care services to Medicaid recipients, announced in June that incentive payments now are available to practices that satisfy speciﬁc Healthcare Effectiveness Data and Information Set (HEDIS) measures. These measures include well-child visits in the third, fourth, ﬁfth and sixth years of life as well as adolescent well visits for children age 12-21. Weight assessment and counseling for nutrition and physical activity also are included. These measures can be combined with well visits to double the incentive payments. Anticipated measures of compliance around well-check metrics include a health history (such as physical and developmental assessments), physical exam, health education and anticipatory guidance. Anticipated measures of compliance around weight and nutrition metrics include BMI percentile documentation and counseling for both nutrition and physical activity.

Some metrics that have been evaluated as a basis for these payments include process activities like counseling patients to quit smoking; outcome activities such as the effects the provider has had on the patient’s health; patients’ satisfaction around the quality of care they received; and facilities, personnel and equipment such as medical record transmission of information.

The Health Care Transformation Task Force is a coalition of private insurers and provider organizations committed to move 75 percent of their contracts into alternative pavement models by 2020. The task force includes Aetna and Blue Cross. They are evaluating payment models for hospitals, private insurance companies and public payers in an effort to accelerate change in healthcare delivery.

It is clear that moving forward, healthcare delivery will be based on measures of quality thought to translate into improved health for our patients. Physicians should familiarize themselves with the recommended measures as best practice and look for innovative ways to provide the education needed to facilitate a healthier patient base.

One of the models moving forward will be pay-for-performance, which is aimed at improving quality and efficiency. Incentives are paid on top of the standard fee-for-service compensation if the provider meets or exceeds certain pre-established metrics for performance. However, moving forward models may penalize providers who do not meet predetermined performance standards, especially for speciﬁc situations like medical errors and hospital readmissions.

Article author Robin LaCroix, MD, is vice chair of Medical Staff Affairs for Children’s Hospital of Greenville Health System (GHS) and a Pediatric Infectious Disease physician at GHS.

CELEBRATIONS

Children’s Hospital of Greenville Health System (GHS) has many reasons to celebrate! Inﬁrmary Debuts at Camp Courage Campers at Pleasant Ridge Camp and Retreat Center this summer were able to receive medical care at the new Dr. Cary E. Stroud Camper Care Center. This center, named for the long-time medical director of Pediatric Hematology/Oncology at Children’s Hospital, beneﬁts campers at Children’s Hospital camps, including Camp Courage and Camp Luv-A-Lung. The center was made possible by a gift from Clement’s Kindness of more than $400,000. Mike McGirr (left), executive director of Clemson University’s FEED & SEED Design Studio, and David Lominack (center), South Carolina market president for TD Bank, present a check to Kerry McKenzie, childhood obesity prevention coordinator with the Bradshaw Institute for Community Child Health & Advocacy.

Farm to Belly Program Receives Donation The Choosy Farm to Belly project, an innovative program designed to educate and encourage healthy eating habits in children as young as 3, received a $50,000 donation from the TD Charitable Foundation in May. The program, finishing its first year at the North Franklin Road Head Start Center, accomplishes its mission by introducing children to fresh vegetables and fruits—not only by taste but also by learning how to cook at home with their families. More than 180 children and their families participated in the pilot program. The donation will enable the program to expand in its second year. Through the program, nutritionist-modified family recipe kits, including fresh local produce, were provided at no cost every other week for 30 weeks. Each child received a weekly recipe bag, with the homework assignment to prepare and enjoy a healthy meal with the assistance of their parents. The program, part of Children’s Hospital’s Bradshaw Institute for Community Child Health & Advocacy, is a collaboration among Children’s Hospital, Clemson University and more than 10 community partners and various volunteers. 20

At the center, patients can receive various treatments while at camp, allowing many patients who previously were unable to attend an opportunity to spend a week at camp with their peers.

High School Donates to Kidnetics® Students and faculty at J.L. Mann Academy raised $151,422.85 for Greenville’s Center for Developmental Services through the school’s Spirit Week in the fall of 2015, and a portion of that money will support a program of Kidnetics, Children’s Hospital’s program for pediatric therapies. The funds will support Kidnetics’ Community and Service Integration Program, an internship program that fosters independence and teaches employment skills to special-needs students. The program involves collaboration from occupational therapists and speech-language pathologists.

Haas Helps Cystic Fibrosis Center Children’s Hospital’s Cystic Fibrosis Center received a $40,000 donation from PGA Charities Foundation on behalf of nine-time PGA Tour event winner Jay Haas. Haas was the U.S. Team Captain for the 2015 President’s Cup in Incheon City, Korea, which the U.S. team won.

CELEBRATIONS

Chaser Visits Children’s Hospital

GOO DNI

GHT GRE ENV

One year after Goodnight Greenville, a picture book penned by Children’s Hospital pediatrician Joseph Maurer, MD, in which proceeds beneﬁt Child Life Services, all 5,000 copies from the ﬁrst printing have sold! Even after accounting for costs to complete the second printing, Child Life has netted $28,000 from book sales. ILLE

Chaser, the dog who knows 1,000 words, visited patients at Children’s Hospital in May. The dog, said to have the largest vocabulary of any nonhuman animal, can even understand and respond to short sentences.

Goodnight Greenville Tops $28,000

MAURE R/B

RADLEY

Written Illustrate by Joe Maurer d by Jose ph Brad ley

For information on where to purchase a copy, visit goodnightgreenville.com.

Dance Marathons Support Child Life Welcome to Children’s Hospital, Vivitar and Chevy! Child Life Services has two new facility dogs. Vivitar is a female golden retriever mix and will be with Taylor Stathes (left) in Radiology. Chevy is a male golden retriever mix and will be primarily with Katie Sullivan (right) on inpatient units. Both dogs had their ﬁrst day at Children’s Hospital on July 18. A third dog will join the Children’s Advocacy Medical Program in September.

Five local colleges and universities—Erskine College, Furman University, University of South Carolina Upstate, Wofford College and Western Carolina University—pledged monies from their individual Dance Marathon fundraisers to Child Life Services at Children’s Hospital. The Dance Marathons raised a total of $256,853, which will be used to fund a child life specialist who will work with children when a parent is in the hospital.

Entercom Recognition Entercom Upstate and its seven radio stations have been a dedicated partner for the Children’s Hospital Radiothon the last eight years, helping bring in more than $2.3 million to Children’s Hospital. To honor their partnership and giving of their time, talent and treasure, Children’s Hospital has renamed the fifth floor playroom, which features the signature fish tank, The Entercom Upstate Room. The naming took place July 26 and served as a kickoff for the upcoming Radiothon on August 4-5. Read more about the Radiothon in our next issue. 21

CASE STUDY

Hospital Child with Acute Respiratory Changes A 4-year-old white female presented to Children’s Hospital of Greenville Health System (GHS) from her primary physician’s office with 10 days of persistent vomiting, abdominal pain, fever, thrombocytopenia and concern for dehydration. At disease onset, she was symptomatic with sore throat, headache and fever. Rapid strep and influenza testing were negative, and she was diagnosed with tonsillitis and began a course of amoxicillin. Her condition improved only slightly until two days before hospital presentation when vomiting, headache and fever (maximum temperature of 103 F) recurred. She was seen at GHS’ Children’s Emergency Center where she had an unremarkable laboratory evaluation, with the exception of a platelet count of 44,000. At that time, she received ceftriaxone, ondansetron and intravenous fluids.

Her vomiting persisted over the next 24 hours, prompting a return to her primary physician. At the office, her platelet count was 18,000.

Admission to GHS

Upon admission to GHS Children’s Hospital, the patient was irritable but consolable. Her vitals included normal respiration rate, blood pressure, temperature and O2 saturation. She had no pertinent past medical or family history, hospitalizations or surgeries. Review of systems demonstrated non-bloody, non-bilious emesis without associated diarrhea as well as headaches that were responsive to ibuprofin, which was given every six hours. She denied other neurologic symptoms. She had been more tired throughout the course of this illness and often would complain of myalgia.

Along with her irritability, her physical exam was consistent with mild dehydration, including tacky mucous membranes and tachycardia. However, she had an appropriate cap refill and skin turgor. She had no increased bruising, petechiae or bleeding. She reported diffuse, nonspecific abdominal tenderness and subjective abdominal pain. A neurologic exam was normal without meningitic signs or findings consistent with increased intracranial pressure.

During admission to the PICU, she displayed mild tachypnea with good oxygen saturation initially. Throughout the day, she became increasingly hypoxic despite nasal cannula oxygen administration. At times, oxygen saturations would temporarily drop to 60%. As her respiratory status worsened, so did her agitation, and she frequently was difficult to console. Her respiratory status and agitation improved dramatically with oxygen administration via a non-rebreather facemask.

Initial management included correction of her hydration status and administration of an antiemetic. Further lab evaluation confirmed thrombocytopenia with a platelet count of 15,000, consisting of mostly large-form platelets. Additionally, she was mildly coagulopathic (PT 18.9, INR 1.6, PTT 36) with increased fibrin consumption (Fibrinogen 75, D-Dimer >20).

After consulting Hematology/Oncology, she began unfractionated heparin via continuous IV infusion per weightbased protocol. Within 12 hours, her clinical status improved dramatically. After approximately 12 hours on this protocol, she transitioned to subcutaneous low molecular weight heparin (LMWH). Despite normal oxygen saturations, she remained on supplementation oxygen to help relieve right heart strain during the initial anticoagulation process.

She exhibited mild transaminitis, increased C-reactive protein (CRP) and mild leukocytosis without left shift. Complete blood count (CBC), complete metabolic panel (CMP) and clean-catch urinalysis were otherwise normal. With lab findings consistent with a consumptive thrombocytopenia and no clear etiology for the patient’s presentation and lab findings, an extensive and urgent evaluation was initiated. Given her tachycardia and presence of a heart murmur the day after admission, electrocardiography (ECG) was performed and noted significant right ventricular hypertrophy. Subsequently, a transthoracic echocardiogram revealed right-ventricular enlargement with decreased right ventricular function. In addition, with her increased agitation and headaches, an MRV head was performed and ruled negative. Abdominal ultrasound, which was conducted because of abdominal pain and persistent emesis, showed anasarca and a small thrombus in the right portal vein with preservation of central flow. Lab evaluation for etiologies was negative, including EBV, CMV, ADAMTS13related TTP and HLH. During the second night of admission, she began to develop intermittent increased work of breathing and tachypnea. CXR was negative. By the next morning, she was mildly hypoxic with saturations dropping to the mid-to-low 90s. Despite this change in respiratory status, her lung sounds were clear to auscultation. Her symptoms were not relieved by supplemental O2 administration via nasal cannula.

Transfer to PICU

The patient’s decline in clinical status prompted an emergent CT of the thorax, abdomen and pelvis, which revealed pulmonary embolism (PE) with a large clot burden bilaterally and evidence of cor pulmonale. She was transferred to the hospital’s Pediatric Intensive Care Unit (PICU) for continuous monitoring and further medical management.

She received two units of platelets during admission; however, by discharge time, thrombocytopenia had resolved and she was otherwise asymptomatic. She was discharged home on Day 8 of hospitalization on a three-month course of LMWH therapy, asymptomatic and with close Cardiology and Hematology/Oncology follow-up. An extensive hypercoagulability evaluation did not reveal an underlying thrombophilia. The inciting event was thought to be adenovirus infection, for which she tested positive.

Thrombocytopenia Evaluation

Pediatric thrombocytopenia has a broad differential that can be turbulent and often feel misguided. Thrombocytopenia should be confirmed with repeat testing to rule out pseudothrombocytopenia. The most common cause of thrombocytopenia in pediatric patients is idiopathic thrombocytopenia purpura (ITP), which often is asymptomatic and 70-80% of the time self-resolves within six months. However, the clinical importance of ITP remains, as 20% of patients develop chronic ITP and require lifelong management. Whether acute or chronic, the clinical importance of ITP remains as it can lead to significant bleeding along with activity and lifestyle restrictions in an effort to prevent significant and life-threatening bleeding. Hence, thrombocytopenia—even its most common form—remains a significant pediatric illness. Initial management of a thrombocytopenic patient involves determination of the patient’s clinical stability. Once a patient is stabilized, determination of etiology is necessary to guide management and therapy decisions. Consumptive thrombocytopenia manifests as large platelets, low fibrinogen and elevated D-Dimer. Examples include disseminated intravascular coagulation, hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura, thrombosis, sepsis and viral infection.

Both sequestration (hemangioma or hypersplenism) and decreased synthesis (malignancy or storage disease) can present with small platelets and hepatosplenomegaly. In well-appearing patients, the consumptive process—indicated by large platelets with normal hemoglobin and white cell count—can be divided into immune (ITP, systemic lupus erythematosus, human immunodeficiency virus or druginduced) and nonimmune (von Willebrand disease or hereditary macrothrombocytopenia). Small platelets with increased mean corpuscular volume and/or congenital anomalies suggest a decreased synthesis, which can be divided into congenital defects (thrombocytopenia-absent radius, Wiskott-Aldrich syndrome or Fanconi anemia) or acquired defects (medication, toxin or radiation-induced).

Depending on the extent of thromboembolism, a patient may exhibit all, some or none of the textbook-associated symptoms. In the setting of antiphospholipid antibody syndrome, rapidly progressive thrombotic storm may develop, involving multiple sites, despite appropriate antithrombic therapy.

Thrombus Alert

Misconceptions Abound

The patient’s laboratory findings—including large platelets, hypofibrinogenemia and elevated D-Dimer—and physical exam were consistent with a consumptive process, most likely thrombosis. Venous thromboembolism (VTE) is rare in children (0.7/100,000), but its prevalence is increasing. VTE in the pediatric population has a bimodal age distribution, peaking in infants less than 1 year of age and again in adolescents. Pediatric patients with deep venous thrombosis and PE are more likely to have an identifiable risk as compared to their adult counterparts, with up to 96% showing a risk factor in some studies. In pediatrics, central venous catheters and peripherally inserted central venous catheters represent the largest risk factors, accounting for 90% of neonate patients and 60% of childhood patients. Malignancy increases the risk of developing PE, with solid tumors being a higher risk than hematologic malignancies. Inherited thrombophilias include deficiencies in antithrombin, protein C and protein S as well as genetic mutations that cause factor V Leiden (activated protein C resistance) and prothrombin G20210A. Sickle cell disease, nephrotic syndrome and antiphospholipid syndrome increase the risk of developing PE. Additionally, 25-50% of patients with SLE develop PE. Determination of etiology of VTE often is based on medical and family history as well as a physical exam. Deep-vein thrombosis in extremities often presents with extremity pain, swelling and discoloration. PE is associated with shortness of breath, pleuritic chest pain, cough, hemoptysis, fever, hypotension and rightheart failure. Cerebral sinovenous thrombosis can present with seizures in neonates or be subtler in older children, to include headache, vomiting, seizures, focal signs or signs of increased intracranial pressure. Renal vein thrombosis may present with hematuria, abdominal mass or thrombocytopenia.

Aside from recurrence of thrombosis, development of postthrombotic syndrome can be a long-term complication. This process involves persistent vessel occlusion, causing venous hypertension, redirecting blood to more superficial vessels, and producing pain, swelling, edema, discoloration and ulceration. Incidence of post-thrombotic syndrome is 17-50% of patients with VTE, peaking during the first two years after thrombus development.

Many misconceptions exist with pediatric PE. Although oral contraceptives increase the risk of PE, its associated incidence has been decreasing with the reduction of estrogen levels in these medications. Another misconception occurs with deep venous thrombosis in children, with the majority occurring in the upper extremities as opposed to lower extremities in adults. Complicating this scenario, venous ultrasound has decreased sensitivity in upper extremities vs. lower extremities. In addition, PE rarely is fatal in pediatrics (2.2%), and it may be asymptomatic if less than 50% of the pulmonary circulation is occluded, unless an underlying cardiopulmonary disorder exists. Finally, many pediatric patients have difficulty describing their symptoms, leading to delayed diagnosis and possible respiratory deterioration. Most likely, our patient’s clinical course is explained by this subjective haziness as her headache and agitation resolved with oxygen administration; her abdominal pain and vomiting may have partially been related to her chest pain.

Conclusion

As occurred with the patient in this case, a systematic yet urgent approach should be used to evaluate and treat patients with thrombocytopenia. PE typically is diagnosed by spiral CT with contrast although pulmonary angiogram remains the gold standard. After stabilization and diagnosis, treatment consists of anticoagulation with the duration of therapy determined by etiology and manifestation of VTE.

Nicholas Kelley, MD, recently completed his Pediatric residency at GHS and now works at Children’s Hospital Spartanburg Night Clinic and at Spartanburg Pediatric Health Center, both part of the system. His article is written in collaboration with Rebecca Cook, MD, and Leslie Gilbert, MD, MSCI, in the hospital’s Division of Hematology/Oncology.

CLINICAL RESEARCH UPDATE Research studies at Children’s Hospital of Greenville Health System (GHS) are approved by the system’s Institutional Review Board.

Pediatric Endocrinology Studies Pediatric Diabetes Consortium: Type 2 Diabetes in Youth Registry Researchers want to determine the best ways to treat type 2 diabetes (T2D) in youth using information collected in this registry. No special testing will be performed, and there are no special office visits. Participants must be diagnosed with T2D and be under age 21. Efficacy and Safety of Liraglutide in Combination with Metformin vs. Metformin Monotherapy on Glycemic Control in Children and Adolescents with T2D This study seeks to evaluate the effectiveness and safety of liraglutide (study drug) and liraglutide placebo in children and adolescents with T2D when given with metformin alone or when given with a combination of metformin and insulin. Participants receive either liraglutide and metformin or liraglutide placebo and metformin. Those being treated with insulin before the study will continue insulin treatment. The study lasts three years. Participants must have T2D and be 1016 years old. Type 1 Diabetes Exchange Researchers want to determine the best ways of managing type 1 diabetes (T1D) by collecting information from people with T1D. A questionnaire will be completed at the time of enrollment; more questionnaires may be completed during enrollment. No special testing will be performed, and there are no special office visits. TrialNet Natural History Study of the Development of T1D TrialNet is a research group dedicated to the study, prevention and early treatment of T1D. This two-part study aims to increase knowledge about the prevention and occurrence of T1D. In the ﬁrst phase, participants are screened for autoantibodies often present in blood before the clinical onset of T1D. These autoantibodies increase the risk of developing this autoimmune disease. If autoantibodies are found during screening, the patient will be asked to take part in the monitoring phase, which includes semi-annual or annual monitoring visits. Participants must have at least one brother, sister, parent, child, aunt, uncle, niece, nephew, cousin, half-sibling or grandchild with T1D.

TrialNet Protocol TN-20: Exploring Immune Effects of Oral Insulin in Relatives at Risk for T1D Researchers want to determine the possible role of oral insulin in altering the immune response to delay or prevent T1D. Those in this small, short-term study receive one of two different doses of oral insulin in an attempt to evaluate its immune effects and impact on progression of diabetes. Participants are chosen from the TrialNet Natural History Study based on the type and number of autoantibodies present and the results of their monitoring visit. They must be 3-45 years old and have a relative diagnosed with T1D. TrialNet Protocol TN-10: Anti-CD3 Mab (Teplizumab) for Prevention of Diabetes in Relatives at Risk for T1D Researchers seek to evaluate the effectiveness of Teplizumab (an investigational drug) in delaying or preventing the destruction of insulin-producing beta cells in people at high risk of developing T1D. Participants are chosen from the TrialNet Natural History Study based on the number of autoantibodies present and the results of their monitoring visit. They must be 8-45 years old and have a relative diagnosed with T1D before age 40. TrialNet Protocol TN-16: Long-term Investigative Follow-up in TrialNet This follow-up observational study monitors enrollees who have received study drug treatment in past prevention and intervention studies for safety. Researchers will evaluate general health, diabetes progression and how much insulin continues to be made over time. Participation includes study visits and collecting blood samples that will be stored and used for scientiﬁc research studies. Those who received study drug treatment in any past prevention or intervention TrialNet study are eligible.

SPECIAL PROGRAM Children’s Hospital of Greenville Health System (GHS), along with the GHS Life Center® Health & Conditioning Club, celebrates a decade of offering the Girls on the Run® International program to over 2,500 participants.

Left: GOTR participants from Greenbrier Elementary School celebrate after completing the 2016 GHS Swamp Rabbit 5K. Right: Participants make their way along the course in the 2015 GHS Swamp Rabbit 5K.

Running Strong for 10 Years At ﬁrst glance, one might think GHS Children’s Hospital’s Girls on the Run (GOTR) program focuses on running and physical activity. But there’s much more to this national organization.

The curriculum helps girls cultivate valuable life skills through … • Developing and improving their competence • Feeling conﬁdent in who they are

“I have a lot of girls who come into the program who don’t like to run,” said Carmine Maio Molina, a local GOTR coach for 14 seasons. “We emphasize that it’s not just a running program. It’s more about empowerment for the girls and positive body image and all-around life lessons.” Girls on the Run International is dedicated to creating a world where every girl knows and activates her potential and is free to pursue her dreams. The program has grown to 225 councils in all 50 states and the District of Columbia. In Greenville, 2016 marks the 10th anniversary for Children’s Hospital’s GOTR program. Twice each year—spring and fall—girls in the third through the eighth grade at schools and community centers throughout the Upstate go through the 20-lesson GOTR curriculum while preparing to run a 5K. This spring, 195 girls took part at 13 sites around the Upstate, noted Kim Hein, MIHS, council director for Children’s Hospital’s Girls on the Run, whose office is housed in the Life Center. Hein works alongside Krista Young, GOTR coordinator. 26

• Developing strength of character • Responding to others and themselves with care and compassion • Creating positive connections with peers and adults • Making contributions to the community “Learning these life skills will help prevent unhealthy and risky behaviors such as physical inactivity and negative body image, and promote good physical, mental, social and emotional health,” Hein explained.

A Toehold on Conﬁdence At the end of the season, the girls took part in the GHS Swamp Rabbit 5K. For many, it was their ﬁrst experience running in a race. Beatrice Galbreath was one such girl.

“I think she liked the sense of accomplishment that she got from having a goal and accomplishing that goal,” said mother Mary Beth Galbreath, adding that she was pleasantly surprised to learn of the emotional and social aspects of the GOTR curriculum. “I liked the emphasis on self-esteem and building strong friendships among girls and helping them support and encourage each other,” she said. “The curriculum taught them to look to each other for good answers and help in navigating the confusing time of late elementary school as they start to get into issues that, at least for parents, are a little scary.”

“I liked the emphasis on self-esteem and building strong friendships among girls and helping them support and encourage each other.” — Mary Beth Galbreath

Hein said in just a few months the coaches are able, through the curriculum, to help girls discover a sense of confidence. “Coaches can take a girl who might be very timid, shy and quiet at the beginning of the 10-week season, and see her blossom and grow more confident and learn to speak up,” Hein said. “You have other girls that have some confidence already, but they become even stronger in their character and take on leadership roles.” Molina said such changes usually occur in small increments, sometimes unnoticeable to the coach from one week to the next. But parents often see a dramatic difference by the end of the curriculum. “I don’t always get to see it, but the parents will tell me, ‘I can’t believe the changes in her,’” Molina shared.

If the Shoe Fits … Another thing the girls learn through the curriculum is about engaging those around them. Hein said each group also is responsible for developing and carrying out a community project. Some projects completed by groups in the spring include the following: • Girls at Oakview Elementary School raised $2,600 for the Make-A-Wish Foundation • Girls in the program at the Greenville County Recreation District’s Pavilion made sock chew toys and bandanas with peanut butter treats for dogs at the Greenville Humane Society, and thank-you cards for the staff and for those adopting animals • Girls at the Caine Halter branch of the YMCA of Greenville collected food for the Ronald McDonald House Many girls repeat the curriculum after their ﬁrst season, Hein added. A new curriculum recently was introduced for middle school girls called Heart & Sole, in which the coach plays more of a facilitating role and lets the girls direct the curriculum.

These girls from Clinton Elementary School are all smiles, having just ﬁnished a trial run for their ﬁrst 5K on May 6.

“They’re taught in the Heart & Sole curriculum to get outside their comfort zones and do small acts of kindness,” Hein stated. “Girls at this age tend to want to be in their own little group of friends, but GOTR teaches them to maybe say hi to the custodian or someone they are familiar with, but don’t really know.” Participants meet with their coaches twice a week. The program costs $199, but Hein said over $10,000 typically is given annually in scholarships to enable all girls to take part. In 2015, InvestiNet generously donated $10,000 to this nonproﬁt program. A program called SoleMates encourages adult runners in the community to help raise funds for the program through their own racing efforts. Learn more about Girls on the Run or being a SoleMate at ghschildrens.org/girls-on-the-run.

Registration is open for the fall season of Girls on the Run!

Visit ghschildrens.org/girls-on-the-run. 27

MEET THE PATIENT For one Beaufort family, the Pediatric Infusion Center at Children’s Hospital of Greenville Health System (GHS) is worth the drive.

An Infusion of Home “We wanted a place that was child-centered, and I like that it has a lot of things geared toward kids,” Cynthia Mills said. “Everything is bright and colorful, and the nurses are very kidfriendly and personable.” Kacy has had ﬁve infusions at Children’s Hospital’s Pediatric Infusion Center, and she feels strongly about it, too. “I really like it because the nurses are very personable,” Kacy stated. “They talk to you like you’ve known them forever.”

Capacity Doubles Not long ago, Children’s Hospital expanded its existing infusion area in the Pediatric Gastroenterology office at the system’s Patewood Medical Campus. Now, the Pediatric Infusion Center is housed at Cross Creek Medical Park (across from Children’s Hospital) and includes eight beds—double the previous capacity. The center serves patients from infants to age 18 and features dedicated staff to make the experience smooth and enjoyable.

Kacy Mills had been having digestive troubles for about two years when she connected with GHS Children’s Hospital in October 2015. The 12-year-old from Beaufort, S.C., had visited a pediatric gastroenterologist close to home, but she and mother Cynthia Mills weren’t happy with the experience. A family friend recommended Liz Dancel, MD, a pediatric gastroenterologist with GHS Children’s Hospital. Dr. Dancel diagnosed Kacy with Crohn’s disease, which led to a treatment plan involving Remicade infusions every ﬁve weeks. The family brought Kacy to Greenville for the infusions, despite more than a three-hour drive each way.

“More and more, medications are being developed that are speciﬁcally targeted to parts of the immune system, and those often are delivered as an IV medication,” explained Jonathan Markowitz, MD, MSCE, medical director for the Division of Pediatric Gastroenterology. “Having a dedicated center where the nursing staff has familiarity with these medications and also has familiarity with how to work with pediatric patients in terms of putting in IVs and keeping patients entertained is a valuable resource.” The Pediatric Infusion Center provides services for patients with a range of conditions, although the BI-LO Charities Children’s Cancer Center at Children’s Hospital has its own infusion space as well. The expansion was a welcome relief for many patients and physicians. Sarah Payne-Poff, MD, medical director of Children’s Hospital’s relatively new Division of Pediatric Rheumatology, said some of her patients were being admitted to the hospital for infusion treatments because of the lack of outpatient space.

“Kids were getting admitted to the hospital because there wasn’t any other way to give them IV therapy,” Dr. PaynePoff pointed out, adding that other beneﬁts to the new center include easy access and coordinated services. “The parking is very easy, which may sound like a small thing, but for kids who have mobility issues, it’s nice that they can park right outside of the door. And the center will draw labs for us when they place the IV, which saves the patient an extra needle stick.”

A Home Away from Home Kacy especially likes the way the staff members make the center feel like home. It is packed with ways for patients to entertain themselves, such as movies, coloring books, iPads and snacks—and outﬁtted with comfortable reclining chairs for times when Kacy just wants to nap.

Both Cynthia and Kacy raved about the nurses at the Pediatric Infusion Center, (from left) Marsha Johnson, RN; Lisa Hiott, RN; and Rebecca Miracle, RN.

Cynthia Mills shared that once when Kacy visited, the nurses removed a ceiling tile and let Kacy decorate it using markers. “When we went back, we saw her ceiling tile in the area where she usually sits,” Mills said. “And there’s a lot of other kids’ art on the ceiling now. The nurses make it so the kids don’t feel like they’re coming there as a guest—they kind of make it another home.” Mills appreciates that the nurses create an environment of family-centered care. In fact, Mills has been so pleased with the service Kacy has received at Children’s Hospital that she plans to make the trip for all of her daughter’s healthcare needs.

The infusion center offers a number of items to keep patients entertained, from DVDs to games and toys.

“We’ve decided, for every new thing that comes up, we’ll always take Kacy to Children’s Hospital because we’ve been completely happy with the service,” she summarized.

Mills has been so pleased with the service Kacy has received at Children’s Hospital that she plans to make the trip for all of her daughter’s healthcare needs. The infusion center provides patients with reclining chairs to sit in during the procedure, and the room is outﬁtted with televisions and kid-friendly murals to give it a more home-like feel. 29

A S K T H E FAC U LT Y

Opioid Abuse Q: How does the opioid epidemic affect my pediatric practice? What can I do to prevent opioid abuse? A: Rates of opioid misuse and abuse have become a top concern for many primary care physicians who treat adult patients. Universal precautions related to prescribing and monitoring for misuse have been adopted by a majority of those who regularly prescribe opioids, but less engagement in these precautions has been noted among physicians caring for children. We need to be active participants in efforts to prevent opioid misuse, not only because the roots of addiction are in adolescence, but also because children are vulnerable to accidental ingestions and medication diversion by their caregivers. Every physician can follow some simple steps to help prevent opioid misuse and abuse: Don’t prescribe opioids by the quart. Kana Enomoto, MA, acting administrator for the Substance Abuse and Mental Health Services Administration, relays a story about her 11-year-old daughter’s postoperative pain prescription. She was dispensed 16 ounces of oxycodone solution but only used 6 teaspoons total during her recovery. It is imperative for prescribers to weigh the benefits and risks of opioid prescriptions and to carefully choose an appropriate amount to dispense. When opioids are prescribed, patients (when appropriate) and caregivers should be informed about the risks of dependence, misuse, abuse and overdose. Query your state’s Prescription Monitoring Program database. Queries can reveal caregiver compliance with filing prescriptions and can show patterns suspicious for diversion. Children are fully dependent on their caregivers and, thus, are vulnerable to being used as a source for prescription drugs. Urine drug testing also can be used to confirm compliance when children cannot accurately report their medication use. Screen for opioid access like you would for gun access. Accidental ingestion and intentional overdose can be just as deadly as playing with guns. Ask families whether any potential caregivers have active controlled-substance prescriptions and where they are kept. Advise that all medications be secured

Pediatric Specialty Services

where children of any age cannot access them and that any unused opioids be returned to a pharmacy or other location with a take-back program. Ask adolescents speciﬁcally about pill-sharing. Prescription medications are more socially acceptable to today’s teens than traditional “street drugs.” A quarter of adolescents report giving away their leftover opioids, and 10% report trading them for other pills. These practices may be common among student athletes, who often sustain injuries and obtain pain-control prescriptions during the school year. Tell families that their words matter. Adolescents who know that their caregivers disapprove of drug use, including misuse of non-prescribed medications, are more likely to make positive choices when faced with temptation or peer pressure. Know where to turn for help. Every community, no matter how small, has stakeholders who are willing to provide aid to children and families. Be aware of your nearest mental health and substance use disorders treatment programs. Access resources to help children exposed to toxic stress and trauma. Research available school-based, faith-based, community and philanthropic programs that may be able to assist your patients and families in need.

With concentrated prevention efforts and full engagement by the medical community, control of the opioid epidemic can be achieved. References The NSDUH report: state estimates of nonmedical use of prescription pain relievers. Rockville, Md.; Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. January 8, 2013. http://www.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedicaluse-pain-relievers.htm. Richardson LP, Fan MY, McCarty CA, et al. Trends in the prescription of opioids for adolescents with non-cancer pain. Gen Hosp Psychiatry. 2011;33(5):423-428. The National Prescription Drug Abuse & Heroin Summit: opening general session presentation. March 29, 2016; Atlanta.

William F. Schmidt III, MD, PhD_______________________________ (864) 455-8401 Medical Director; Chairman, Department of Pediatrics Matthew P. Grisham, MD __________________________________________ 455-7895 Pediatric Residency Program Director Russ C. Kolarik, MD _______________________________________________ 455-7844 Medicine-Pediatrics Residency Program Director Desmond P. Kelly, MD _____________________________________________ 454-5115 Developmental-Behavioral Fellowship Program Director Adolescent Pediatrics ______________________________________________ 220-7270 Allergy and Immunology ___________________________________________ 675-5000 Ambulatory Pediatrics _____________________________________________ 220-7270 Cardiology _______________________________________________________ 454-5120 Child Advocacy Medical Program____________________________________ 335-5288 Critical Care ______________________________________________________ 455-7146 Developmental-Behavioral Pediatrics _________________________________ 454-5115 Emergency Pediatrics ______________________________________________ 455-6016 Endocrinology ____________________________________________________ 454-5100 Gastroenterology__________________________________________________ 454-5125 Genetics _________________________________________________________ 250-7944 Hematology/Oncology ____________________________________________ 455-8898 Infectious Disease _________________________________________________ 454-5130 Minor Care (Spartanburg Night Clinic) _______________________________ 804-6998 Children’s Hospital After-Hours Care ______________________________ 271-3681 Neonatology _____________________________________________________ 455-7939 Nephrology & Hypertension ________________________________________ 454-5105 Neurology________________________________________________________ 454-5110 Neurosurgery _____________________________________________________ 797-7440 Newborn Services _________________________________________________ 455-3512 Ophthalmology ___________________________________________________ 454-5540 Orthopaedic Oncology _____________________________________________ 797-7060 Orthopaedic Surgery_______________________________________________ 797-7060 Plastic Surgery ____________________________________________________ 454-4570 Pulmonology _____________________________________________________ 454-5530 Radiology ________________________________________________________ 455-7107 Rheumatology ____________________________________________________ 454-5004 Sleep Medicine ___________________________________________________ 454-5660 Supportive Care Team (formerly Palliative Care) _______________________ 455-5129 Surgery __________________________________________________________ 797-7400 Urgent Care (Anderson) ___________________________________________ 512-6544 Urology __________________________________________________________ 454-5135

Children’s Hospital Programs BI-LO Charities Children’s Cancer Center _____________________________ 455-8898 Bradshaw Institute for Community Child Health & Advocacy ____________ 454-1100 Bryan Neonatal Intensive Care Unit __________________________________ 455-7939 Child Life ________________________________________________________ 455-7846 Cystic Fibrosis Clinic _______________________________________________ 454-5530 Family Connection ________________________________________________ 331-1340 Ferlauto Center for Complex Pediatric Care ___________________________ 220-7270 Gardner Center for Developing Minds ________________________________ 454-5115 Infant Apnea Program _____________________________________________ 455-3913 International Adoptee Clinic ________________________________________ 454-5130 Kidnetics® (pediatric therapies) _____________________________________ 331-1350 Neonatal Developmental Follow-up Services __________________________ 331-1333 New Impact (weight management) ____________________________ 675-FITT (3488) Office of Philanthropy & Partnership/CMN ___________________________ 797-7735 Pediatric HIV Clinic ________________________________________________ 454-5130 Safe Kids™ Upstate _______________________________________________ 454-1100 Spiritual Care _____________________________________________________ 455-7942 Wonder Center ___________________________________________________ 331-1380 Day treatment for medically fragile children

For admission to Children’s Hospital: (864) 455-0000 This number connects you to GHS’ Patient Referral and Transfer Center, which can handle all arrangements for admission. You also may call 455-7000 and ask the operator to page the admitting resident. Neonatal Transport _________________________________ (864) 455-7165

www.cdc.gov: CDC Guideline for Prescribing Opioids for Chronic Pain

To reach a Children’s Hospital doctor or program, call 1-800-4RBUDDY.

www.samhsa.gov

Pediatric Outpatient Service Locations Call the appropriate Greenville number above for an appointment.

www.drugabuse.gov

Article author Jennifer Hudson, MD, is medical director of Newborn Services at GHS Children’s Hospital.

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GHS Vision Transform health care for the beneﬁt of the people and communities we serve. GHS Mission Heal compassionately. Teach Innovatively. Improve constantly. GHS Values Together we serve with integrity, respect, trust and openness.

For information about Children’s Hospital giving opportunities, call GHS’ Office of Philanthropy & Partnership at (864) 797-7732 or visit ghsgiving.org.

GHS Opens Center for Pediatric Medicine–West Children’s Hospital of Greenville Health System has opened a pediatric center in West Greenville, creating a patientcentered medical home in the heart of that neighborhood. The Center for Pediatric Medicine–West, located at 5 W. Main St., is open from 8 a.m.-5 p.m. Monday through Friday. The center is expected to serve about 7,000 patients annually, most of whom are on Medicaid. The center also has social work services on-site to assist families with connecting to community resources. The staff includes a translator, as well as a number of bilingual providers and personnel, to better serve the Hispanic population. With a community-based approach to medicine, the Center for Pediatric Medicine–West focuses on nurturing patientprovider relationships and creating familiarity between the doctors, nurses and staff of the center and the residents of the neighborhood through an outreach program. The center aims to reduce the need for families in the community to use emergency care for routine health issues such as common colds, ear infections, gastrointestinal viruses and newborn concerns. This office is Children’s Hospital’s third location for Center for Pediatric Medicine practices. Other sites are near Greenville Memorial Hospital and near North Greenville Outpatient Center in Travelers Rest.

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