A journal of The Children’s Medical Center of Dayton

A journal of The Children’s Medical Center of Dayton
SUMMER 2010
VOLUME 22
NUMBER 2
CME
accredited articles
FREE CME
credits available
Implementation of a nitrous
oxide service Page 3
Undifferentiated high grade
pleomorphic sarcoma Page 6
Evaluating for osteroporosis
at Dayton Children’s Page 7
Frequency of childhood cancer
types diagnosed and treated
at Dayton Children’s Page 9
Genetic testing update Page 11
News and Updates Page 15
2
Pediatric
Forum
A journal of
The Children’s
Medical Center
of Dayton
SPONSORSHIP/ACCREDITATION INFORMATION
Physician accreditation
statement and credit
designation
Wright State University (WSU)
Boonshoft School of Medicine is
accredited by the Accreditation
Council for Continuing Medical
Education to provide continuing
medical education for physicians.
WSU Boonshoft School of Medicine
designates this educational activity
for a maximum of 2.0 AMA PRA
Category 1 Credit(s)TM. Physicians
should only claim credit commensurate with the extent of their participation in the activity.
1 Children’s Plaza
Dayton, Ohio
45404-1815
Obtaining CME credit
937-641-3000
To obtain CME credit, read, reflect on
childrensdayton.org articles, complete and return the answer sheet and program evaluation to:
Pediatric Forum
is produced for
the professional
staff and referring
physicians of
The Children’s
Medical Center
of Dayton by
the marketing
communications
department.
The purpose of
Pediatric Forum
is to provide
information
and news about
pediatric health
care issues
and to provide
information
about clinical
services and
management
issues of Dayton
Children’s.
Sue Strader, coordinator
Department of Continuing
Medical Education
The Children’s Medical Center
of Dayton
One Children’s Plaza
Dayton, OH 45404-1815
Fax 937-641-5931
The answer sheet and program evaluation must be received by August 31,
2011 for the credit to be awarded.
Upon completion of all requirements,
WSU will issue a memorandum of
credit to you for your permanent
records.
As an organization accredited for
CME, WSU Boonshoft School of
Medicine fully complies with the
legal requirements of the Americans
with Disabilities Act rules and
regulations. If any participant is in
need of accommodations, written
requests should be submitted at
least one month in advance.
Target audience
This education activity is designed for
pediatricians, family physicians and
related child health care providers.
Educational objectives
• Articles will review commonly
encountered clinical conditions and
provide updates in pediatric medical
and surgical care.
• Each individual article will have
activity-specific learning objectives.
Affiliations/disclosures
of authors
Lucinda Brown, RN
The Children’s Medical Center
of Dayton
Elizabeth Ey, MD
The Children’s Medical Center
of Dayton
Dawn Light, MD, MPH
The Children’s Medical Center
of Dayton
L. David Mirkin, MD
The Children’s Medical Center
of Dayton
Ruthann Pfau, PhD
The Children’s Medical Center
of Dayton
Jenna J. Wheeler, MD
Wright State University Boonshoft
School of Medicine
L. David Mirkin, MD
Dr. Mirkin has nothing to disclose with
regard to commercial support. Dr. Mirkin
does not plan on discussing unlabeled/investigational uses of a commercial product.
Ruthann Pfau, PhD
Dr. Pfau has nothing to disclose with
regard to commercial support. Dr. Pfau
does not plan on discussing unlabeled/investigational uses of a commercial product.
Jenna J. Wheeler, MD
Ms. Wheeler has nothing to disclose with
regard to commercial support. Ms. Wheeler
does not plan on discussing unlabeled/investigational uses of a commercial product.
The content and views presented
are those of the author and do not
necessarily reflect those of the
publisher, The Children’s Medical
Center of Dayton. Unlabeled use of
products may be mentioned. Before
prescribing any medicine, primary
references and full prescribing
information should be consulted.
Author conflict of
interest information
It is the policy of Wright State University to ensure balance, independence,
objectivity and scientific rigor in all
educational activities. All authors
contributing to our programs are
expected to disclose any relationships
they may have with commercial
companies whose products or services
may be mentioned so that participants
may evaluate the objectivity of the
program. In addition, any discussion of
off-label, experimental or investigational
use of drugs or devices will be disclosed
by the authors. Contributing authors
reported the following:
Lucinda Brown, RN
Ms. Brown has nothing to disclose with
regard to commercial support. Ms. Brown
does not plan on discussing unlabeled/investigational uses of a commercial product.
Elizabeth Ey, MD
Dr. Ey has nothing to disclose with regard
to commercial support. Dr. Ey does not
plan on discussing unlabeled/investigational uses of a commercial product.
Dawn Light, MD, MPH
Dr. Light has nothing to disclose with
regard to commercial support. Dr. Light
does not plan on discussing unlabeled/investigational uses of a commercial product.
EDITORIAL BOARD
Arthur Pickoff, MD, chairperson
Cindy Asher, RN
Emmett Broxson, Jr, MD
Lisa Coffey
Elvira R. Jaballas, MD
L. David Mirkin, MD
Sherman Alter, MD
Continuing medical education liaison
David Kinsaul, FACHE
President and Chief Executive Officer
Thomas Murphy, MD, MPH
Vice President for Medical Affairs
Jeffrey Christian, MD
Chairman of the Professional Staff
NITROUS OXIDE —
IMPLEMENTATION OF A NITROUS OXIDE SERVICE
Objectives
Following the completion of
this article, the reader should
be able to:
1. Discuss the history of the use
of nitrous oxide.
2. Identify patients who can
benefit from the use of
nitrous oxide.
3. Explain the contraindications
and side effects of nitrous
oxide.
Overview and History
Since its discovery 150 years ago,
nitrous oxide (N2O) has been
used to provide pain and anxiety
relief for patients undergoing
surgical procedures. Nitrous
oxide/oxygen (N2O/O2) is often
used as an adjunct to supplement
general anesthesia. Many disciplines use N2O/O2 as an effective means to provide pain and
anxiety control during outpatient
and ambulatory procedures. It
has been used for dental procedures, medical imaging studies
and procedures performed in the
emergency department (ED).
The use of N2O/O2 has gained
popularity for many reasons. This
inhaled gas can be titrated easily
to meet the patient’s physiologic
and psychological needs. The gas
leaves the patient’s system quickly
and can be reversed with minimal
side effects.1
Nitrous oxide has been cited in
the literature for years as a safe
and effective drug. In the late
1800s, a professor documented
its use in 193,000 cases with no
adverse reactions. Ruben, a
Danish researcher, cites three
million cases using N2O/O2
in the dental office without any
adverse reactions.1
More recently used as a mild
analgesic and sedative, N2O is
administered with oxygen from
safe equipment that allows no
more than 70% N2O and no less
than 30% O2 to be delivered at
any time. The pediatric patient
is mildly sedated and can respond
to commands. Protective reflexes
such as cough and gag are left
intact and the elimination of the
drug is rapid. Recovery is complete in a short time and the child
may go home. This is unlike the
period of time the child must stay
to recover after receiving opioids
and/or benzodiazepines.
The American Society of Anesthesiologists (ASA) and the American
Dental Association (ADA) have
published guidelines which speak
to the use of N2O/O2. These
guidelines were developed in 2002
and direct the trends and practice
of N2O/O2.2,3 ASA guidelines
were intended for use by non-anesthesiologists in practice settings
where children undergo painful
procedures and are required to
be still for a period of time. Both
sets of guidelines refer to the use
of N2O/O2 in concentrations
greater than 50% and the use of
nitrous oxide with other medications such as midazolam. Moderate sedation is achieved in these
cases. The use of nitrous oxide
alone and in concentrations less
than 50% produces anxiolysis
in the pediatric patient and not
moderate sedation.
3
What is nitrous
oxide and how is
it administered?
Nitrous oxide is a colorless,
odorless gas which has anxiolytic,
amnesic and mild-to-moderate
analgesic properties. It has a
rapid onset of effect and rapid
recovery, typically taking less than
five minutes. The child is able
to remain awake, follow minimal
commands and have minimal side
effects. Procedures using nitrous
oxide include lumbar puncture,
bone marrow aspiration, venous
cannulation, dressing changes and
urethral catherization.4
Standard delivery devices that provide a continuous flow of nitrous
oxide, titratable from 0-70%,
have a fail-safe mechanism which
terminates nitrous oxide flow in
event of cessation of oxygen flow.
These systems also have a non-rebreathing valve to prevent exhaled
gas from contaminating the system and an emergency air inlet. A
scavenging apparatus designed to
eliminate exhaled nitrous oxide is
an integral part of the equipment
and minimizes exposure of health
care providers to nitrous oxide.
Dental nasal hoods are used to
administer nitrous oxide. These
hoods are scented but also can be
scented by the choice of the child
based on his or her favorite flavor.
Nitrous oxide does have an abuse
potential so when not in use, the
gas needs to be secured in a locked
storage cabinet.1
Elizabeth
Ey, MD
Elizabeth Ey, MD, is
medical director of
medical imaging at
Dayton Children’s.
Dr. Ey is board certified in diagnostic
radiology and has a
certificate of added
qualification in
pediatric radiology.
She performs angiography and interventional studies such as
drainages, biopsies
and intraoperative
image guidance.
Lucinda
Brown, RN
Lucinda Brown, RN,
is a clinical nurse
specialist at Dayton
Children’s. She is on
the board of directors for the Society
of Pediatric Nurses
and the American
Pediatric Surgical
Nurses Association.
She is also a certified
Pediatric Advanced
Life Support faculty.
Program development
An interdisciplinary team was
formed at The Children’s Medical
Center of Dayton to implement a
nitrous oxide program in medical
imaging and the ED. This team
was a component of a larger team
which had spent two years reviewing the literature and developing a
procedural pain pathway including the use of patient preparation/
coaching/distraction, topical
A literature search was performed
and programs reviewed across the
United States including a program
in place at Minnesota Children’s.4
Hospital approval was obtained
for the service and the process.
A policy, procedure, order set,
documentation forms and patient
education materials were
developed (Figure 1). Practitioners
received extensive education and
were credentialed to order or educated to administer nitrous oxide.
Child life specialists were involved
in this project as the use of guided
imagery or helping patients think
of a “happy place” is an important part of the successful use of
Figure 1
Would you like
Nitrous Oxide to
be used during
your child’s
procedure
again?
83%
NO
Did you feel that
the use of nitrous
oxide helped your
child tolerate the
procedure better by
relaxing?
YES
Nitrous Oxide Family Survey
NA
Children who are candidates for
nitrous oxide use must be three
years of age and have a pre-procedure assessment. When used by
itself (without other medications)
at concentrations lower than 50%,
nitrous oxide is not considered
to provide moderate sedation;
however, the process for moderate sedation is followed. This
process includes a pre-procedure
assessment, consent for use and
discharge by use of moderate sedation criteria. Contraindications
include any condition where air
is trapped in the body (pneumothorax, intestinal obstruction and
middle ear occlusion), increased
intracranial pressure, pregnancy,
vitamin B12 deficiency, impaired
level of consciousness, history of
bleomycin administration, intoxication with drugs or alcohol and
current or recovering drug addiction. In addition, nitrous oxide
can only be delivered via a staff
member who has received education and training. Side effects
may include lethargy, headache,
confusion, dizziness and nausea.
The potential for side effects are
decreased when the patient has
a slow induction and emergence
from the gas.
anesthetics and sedation.
Dentists and dental techs routinely administer nitrous oxide across
the United States; however the use
of nitrous oxide by other health
care providers is limited by state
law. Ohio does allow nurses to
administer nitrous oxide by order
of physicians but not advanced
practice nurses.
13%
4%
YES
Patient selection and
contraindications
NO
4
91%
9%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Previous methods used were distraction, positioning and versed.
Figure 2
Nitrous Oxide Family Survey
How would you rate the overall effectiveness of Nitrous Oxide?
90
78%
80
70
60
50
40
30
20
10
0
13%
4%
4%
0%
Not
Effective
Somewhat
Effective
Effective
There was a total of 23 family surveys conducted.
Very
Effective
NA
nitrous oxide. The dental service
was instrumental in providing the
expertise to initiate this program.
An audit tool also was initiated
so that data could be obtained
regarding patient, family and
staff satisfaction.
Process
Nitrous oxide sedation has been
successfully implemented in medical imaging at Dayton Children’s.
This form of sedation is used primarily for bladder catheterization
prior to voiding cystourethrography (VCUG). One advantage of
nitrous oxide sedation is the sedation effect wears off quickly which
permits the child to sense how full
the bladder is and to void during
the procedure when requested.
Nitrous oxide is offered when the
procedure is scheduled and requested by the referring physician.
The patient must meet the appropriate guidelines for nitrous oxide
and must follow the pre-sedation
guidelines for moderate conscious
sedation. Staff in medical imaging have been pleased with the
rapid recovery for patients after
nitrous oxide; however, the implementation time for entire nitrous
oxide sedation is lengthy, still
approximately two hours. Discussions are ongoing to determine
if this can be shortened and made
more efficient. When patients
and families are surveyed regarding their experience with nitrous
oxide sedation, the comments
have been very positive.
Data review
To evaluate the effectiveness of
nitrous oxide use, a survey is given
to the family and the administering nurse providing the nitrous
oxide to the patient. The return
of these surveys has been significant and the data is collated by
quality resource management.
Several questions are asked on the
family survey but the three most
important questions/responses
are regarding effectiveness, ease of
use and probability of using again
(Figure 2). Notably, families
felt nitrous oxide helped their
children tolerate the procedure
by relaxing and they welcome the
use of the nitrous oxide again.
The staff felt nitrous oxide was
effective (81 percent), easy to use
(100 percent) and that they would
use the gas again (88 percent).
The staff also noted that patients
exhibited very few side effects
(94 percent felt no side effects
at all). Plans to expand the service
include increasing utilization
in the ED and laboratory for
patients who are challenged
with blood draws.
References
1. Clark, M and Brunick, A.
Handbook of Nitrous Oxide and
Oxygenation. Second Edition.
Philadelphia: Mosby, 2003.
2. ASA Task Force: Practice
guidelines for sedation and analgesia by non-anesthesiologists,
Anesthesiology 96(4):1004, 2002.
3. American Dental Association:
Guidelines for the use of conscious sedation, deep sedation,
and general anesthesia for dentists, ADA House of Delegates,
October, 2002, American Dental
Association.
4. Farrell, M, Drake, G, Rucker,
D, Finkelstein, M, and Zier, J.
Creation of a Registered NurseAdministered Nitrous Oxide
Sedation Program for Radiology
and Beyond. Pediatric Nursing.
2008; 34:29-35.
5
CME Questions
1. Contraindications to the
use of nitrous oxide include
a.Pneumothorax
b.Concurrent use of
vancomycin
c.Anemia
d.Increased blood pressure
2. Side effects of rapid
induction of or emergence
from nitrous oxide include
a.Respiratory arrest
b.Decreased blood pressure
c.Hallucinations
d.Nausea
3. The maximum concentration of nitrous oxide that
can be administered is
a.80%
b.50%
c.70%
d.30%
6
L. David
Mirkin, MD
David Mirkin,
MD, serves as
medical director
of pathology
and the clinical
laboratory at
Dayton Children’s.
He is professor of
pathology and
pediatrics at
Wright State
Boonshoft
School of
Medicine.
UNDIFFERENTIATED HIGH GRADE
PLEOMORPHIC SARCOMA
Case Study
Case Discussion
A 16-year-old male presented
with a large lumbar mass extending from T10 to L4 without involvement of the muscles or spinal structures. A birthmark had
developed in a cluster of moles
that was removed with neotil at 9
years of age. Ten months before
the current visit, the mass began
to enlarge and after being treated
with coconut oil, by suggestion of
a naturalist, eroded and bled. The
mass was removed surgically.
Undifferentiated high grade
pleomorphic sarcoma is rare in
children. The most commonly
affected site is the deep soft tissue
of the extremities. A few patients
present with malaise, fever and
weight loss, and in the case of
retroperitoneal lesions, abdominal
pain. It may appear after a long
interval (average 10 to 12 years)
following radiation and may also
arise in chronic ulcers and scars.
Local recurrence in most series
has been in the range of 50 to 60
percent and metastases occurred in
20 to 30 percent
of cases.
The surgical specimen consisted
of a dark red ovoid, one half
covered by extensively ulcerated
skin, 18.l5 cm x 17.0 cm x 14.0
cm, weighing 1,612 g. The deep
surface of resection showed a
circumscribed fascia-like appearance. Sectioning demonstrated a
massive hemorrhage and a
Objective
yellow central
Following the completion of
area of necrothis article, the reader should
sis 6.0 cm in
be able to:
diameter.
1. Recognize the main clinical
and morphological features
of this neoplasm and to
evaluate some of the
therapeutic strategies.
Microscopic
examination
revealed a
highly cellular,
markedly pleomorphic and extensively necrotic
malignant neoplasm infiltrating
margins of resection composed
of spindle or round, occasionally
multinucleated cells with generous cytoplasm. Marked anaplasia
and atypical mitotic figures were
observed (Figure 1). Differential
diagnosis included pleomorphic
rhabdomyosarcoma, fibrosarcoma, melanoma and pleomorphic
sarcomatoid carcinoma. Immunoperoxidase stains for myogenin,
desmin, myo-D1, actin and S100
were negative.
Ultrastructure
shows relatively
undifferentiated, non-specific
fibroblast-like or
histiocytic-like
features. Surgery, adjuvant
radiotherapy and
chemotherapy are
part of the treatment. Doxorubicin and ifosfamide have been used
for over 15 years for sarcomas
of the extremities. Gemcitabine
and docetaxel have been tried as a
useful combination in metastatic
sarcoma.
References
1. Weiss SW and Goldblum JR.
Malignant fibrous histiocytoma
(pleomorphic undifferentiated
sarcoma). Soft Tissue Tumors.
5th ed. Philadelphia, PA: Mosby;
2008:406-414.
2. Montgomery E. Malignant
fibrous histiocytoma. In:
Silverberg SG et al eds. Surgical
Pathology and Cytopathology. 4th
ed. Philadelphia, PA: Churchill
Livingstone; 2006: 333-335.
3. Fletcher CDM, van den Berg
E, Molenaar WM. Pleomorphic
malignant fibrous histiocytoma/
undifferentiated high grade
pleomorphic sarcoma. In: Fletcher
CDM, Unni KK, Mertens F.
eds. Tumours of Soft Tissue and
Bone. Lyon, France: IARCPress;
2002:120-122.
CME Questions
4. Undifferentiated high grade
pleomorphic sarcomas are
rare in children.
a.True
b.False
5. The most commonly affected
site is the deep soft tissue of
the extremities.
a.True
b.False
6. The neoplasm may arise in
chronic ulcers and scars.
a.True
b.False
EVALUATING FOR OSTEROPOROSIS AT
DAYTON CHILDREN’S
Objectives
Following the completion of
this article, the reader should
be able to:
1. Describe indications for bone
densitometry in children.
2. Apply normative T and Z
scores in planning clinical
interventions.
3. Appreciate the costs of CT
densitometry for children.
QCT uses the in-house CT
and provides a technically more
accurate estimate of bone density.
No measurable gonadal exposure
for the low-dose methods normally used for QCT exists. The
QCT radiation exposure to the
bone marrow is five millirem to
the whole body, compared to a
chest x-ray which would be about
3 millirem to the whole body.
Why Screen for Bone
Mineral Density?
Medical Imagers at Dayton
Children’s can finally confidently
evaluate pediatric patients for
evidence of osteopenia and osteoporosis. Our newest CT scanner
is capable of QCT (Quanitative
Computed Tomography) and
we have concluded that UCSF
pediatric normative data is an
appropriate comparison standard
for our population.
Osteopenia results when bone
synthesis is not enough to offset
normal bone loss. This can be
suggested on plain films and
is a strong risk factor for
osteoporosis. Osteoporosis is
a condition characterized by a
decrease in the density of bone,
decreasing its strength and
resulting in fragile bones. The
amount of calcification in the
bones can be calculated and
completed using DXA (dual
energy absorptiometry) or QCT.
DXA vs. QCT bone
densitometry
DXA uses a smaller radiation
dose, but requires a standalone
machine and is less useful in patients with arthritis, severe spinal
deformity and prior surgery.
1. To establish a diagnosis of
osteoporosis or assess its severity
in the context of general
clinical care.
2. To monitor bone density in
patients receiving glucocorticoid
therapy.
3. To diagnose patients at
risk for bone loss due to
chemotherapy, neuromuscular
weakness, endocrine disease and
non-weight bearing.
Which are Common
Indications for
Screening in Children?
4 Cystic Fibrosis
4 Family History of
Osteoporosis
4 Numerous fractures
4 Chronic Renal Disease
4 Long-term use of steroids
4 Muscular Dystrophy
4 Disorders/FTT
4 Cachexic /Malabsorption
4 Cerebral Palsy
4 Endocrine Disorders
The CPT code for QCT bone
densitometry is 76070, CT Bone
Density study.
How is QCT obtained?
A lateral scout view allows the
technologist to localize the vertebral levels. A 1 cm thick scan is
obtained at L1 and L2. For each
level, the average bone mineral
density in (mg/cc K2HPO4)
is calculated for a 5 cc voxel of
vertebral marrow. These values
are matched to age/gender similar
standard values.
Patients are assessed based on
where their scores fall on a bell
curve. The T and Z scores are
standard deviation values for the
patients compared to the mean.
T-score shows the amount of bone
the patient has compared to a
young adult of the same gender
with peak bone mass.2
4 >-1 = normal
4 -1 to -2.5 = osteopenia
4 <-2.5 osteoporosis
Z score is a T-score corrected for
age. Most experts recommend
using Z-scores rather than
T-scores for younger men,
premenopausal women
and children.
Hematology, pulmonary and
nephrology clinicians order
majority of scans, however a
relatively large population of
other children probably can
benefit from screening. Though
most children tested are normal,
25 percent are osteopenic and
13 percent are osteoporotic.
7
Dawn Light,
MD, MPH
Dawn Light, MP,
MPH, completed
a family practice
fellowship in faculty
development at the
University of North
Carolina in Chapel
Hill in addition to a
faculty development
fellowship and a
diagnostic radiology
residency at Madigan
Army Medical Center in Washington.
Dr. Light is a member of the American
College of Radiology
and the Order of
Military Medical
Merit among others.
8
References
1. Gilsanz V, Varterasian M,
Senac MO, Cann CE. 1986.
Quantitative spinal mineral
analysis in children. Ann Radiol
29:380-382.
2. Gilsanz V. Bone density in
children: a review of the available
techniques and indications European Journal of Radiology, Volume
26, Issue 2, Pages 177-182.
3. Gilsanz V, Gibbens DT, Roe
TF, Carlson M, Senac MO, Boechat MI, Huang HK,Schulz EE,
Libanati CR, Cann CE. 1988.
Vertebral bone density in children: Effect of Puberty. Radiology
166:847-850
4. Clark EM, Tobias JH, Ness
AR. Association Between Bone
Density an Fractures in Children:
A Systematic Review and Metaanalysis. Pediatrics Vol. 117 No.
2 February 2006, pp. e291-e297.
5. http://www.nof.org/osteoporosis/bmdtest.htm example: Curesearch. Available at http://nccf.
org/our_research/index. Accessed
March 11, 2008.
Table 1
Normal
Osteopenia
Osteoporosis
The Initial Experience at Dayton Children’s
BURK
ALL
BMT
ALL
LCH
ALL
HL
AED
REN
ALL
AML/BMT
CP
ALL
OSARC ALL
FX
GI
ALL
ALL
ST
NHL
AED
CF
ALL
ALL
FX
ALL
HL
CGD
ST
ALL
REN
TH/GH
ALL
REN
CP
DEF
ALL
BURK
REN
ALL/NHL ALL
ALL
BMT
FX
HODG
ST
ALL
CF
ALL
ALL
ST
RENAL
RENAL
ALL
FX
ST
CF
FX
RENAL
ST
TEF
ALL
REN
FX/CP
ALL
ALL
ALL
SLE
ALL/BMT FX/CP
FX
OP
+1
Z-score
-2.6
BR
CA
-5
CME Questions
7. How can you explain the radiation dose of QCT to a parent?
a.The QCT radiation exposure to the bone marrow is
5 millirem to the whole body compared to a chest x-ray
which would be about 3 millirem to the whole body
b.There is no radiation with QCT
c.There is no radiation with DEXA scan
d.None of the above
6. http://www.niams.nih.gov/
Health_Info/Bone/Bone_Health/
Juvenile/default.asp
8. T-score compares your patient to a young adult of the
same gender with peak bone mass.
a.True
b.False
7. http://www.bestbonesforever.
gov/ (patient site)
9. Z score is a T-score corrected for age.
a.True
b.False
8. http://www.qct.com/Pages/
What_is_QCT.html
10. Which of the following is not a common indication for
bone densitometry?
a. Long term steroid use for pulmonary and
heme-onc patients
b. Patients with renal disease
c. Osteogenesis Imperfecta
d. Patients with CP
e. Patients with history of multiple fractures
FREQUENCY OF CHILDHOOD CANCER TYPES
DIAGNOSED AND TREATED AT DAYTON CHILDREN’S:
A COMPARISON
TO NATIONAL
DATA.
Objectives
Following the completion of
this article, the reader should
be able to:
1. Understand the types of
childhood cancer diagnosed
at Dayton Children’s (DC)
from 1994-2007.
2. Compare the types of pediatric cancer diagnosed at this
institution from 1994- 2007
to a national database of
childhood cancer pertaining
to the same interval.
This study examines the occurrence of various cancers diagnosed
and treated at Dayton Children’s
(DC) as compared to national
occurrence trends from 19942007 and to determine, of the
10 cancers selected, if DC has an
incidence rate for a particular
cancer that varies significantly
from national data. This study
included patients </= 20 years old
(yo) at time of diagnosis with a
primary pathologic diagnosis for
one of the following: leukemia,
brain and nervous system tumor,
Wilms tumor, neuroblastoma,
Hodgkin lymphoma, non-Hodgkin lymphoma (NHL), rhabdomyosarcoma, retinoblastoma,
osteosarcoma or Ewing sarcoma.
Background
While the five-year survival rate
for childhood cancer has been
rising over past decades, approximately one out of every 315
children less than 20 years of age
will be diagnosed with some form
of cancer. Approximately 12,500
new childhood cancer diagnoses
in the United States are made annually. Of the total annual cancer
diagnoses, leukemias account for
30 percent, brain and nervous sys-
tem tumors 22 percent, neuroblastomas 7 percent, Wilms tumors
6 percent, non-Hodgkin lymphomas (NHL) including Burkitt
4.2 percent, Hodgkin lymphomas
4 percent, both rhabdomyosarcomas and retinoblastomas 3 percent
each, osteosarcomas 2 percent,
Ewing sarcomas 1.8 percent and
the remaining 20 percent are
attributed to various other
cancer types.
Methods
Data were compiled from the
Oncolog reporting system used by
DC to document all cancer cases
diagnosed and treated at this facility from 1994-2007 totaling 728
patients. Data including patient’s
medical record number, age at diagnosis and year of diagnosis were
recorded. Diagnoses were confirmed using the Powerpath pathology reporting system to obtain
each medical record number and
corresponding histology/pathology reports. Medical records were
viewed via the HBOC network
for all patients who did not have a
definitive pathology report in the
Powerpath system. Exclusion criteria included any patient with an
unclear diagnosis (three patients),
those patients age >/= 21 yo at
time of diagnosis (three patients)
and patients with a secondary
cancer or nonmalignant diagnosis
(five patients) for a population of
717 patients after exclusion.
The data obtained were then
compared with national data,
regarding the percent of overall
childhood cancers for which each
specific diagnosis is responsible.
Ten specific cancer diagnoses were
compared to national data using
the exact binomial method (Table
1). The goal was to find any variation from national data at DC
9
L. David
Mirkin, MD
David Mirkin, MD,
serves as medical
director of pathology and the clinical
laboratory at Dayton
Children’s. He is
professor of pathology and pediatrics
at Wright State
University Boonshoft
School of Medicine.
and
Table 1
1994-2007 Dayton Children’s cancer occurrence trends
compared with national occurrence trends
N=717
# Patients with diagnosis
Percent N
*Wilms tumor
25
3.49
National percent
6.00
*Ewing sarcoma
24
3.35
1.80
Total leukemia
208
29.01
30.00
ALL
167
23.29
AML
37
5.16
JMML
3
0.42
APML
1
0.14
Total brain/nervous
system tumors
160
22.32
Glioma, all types
31
4.32
Astrocytoma, other types
30
4.18
Other
30
4.18
Medulloblastoma/PNET
28
3.91
Pilocytic astrocytoma
20
2.79
Ependymoma
17
2.37
GBM
3
0.42
Schwannoma
1
0.14
Neuroblastoma
36
5.2
Total lymphoma
63
8.79
Hodgkin lymphoma
36
5.02
Non-Hodgkin lymphoma
27
3.77
4.20
Osteosarcoma
22
3.07
2.00
Rhabdomyosarcoma
15
2.09
3.00
Retinoblastoma
13
1.81
<3.00
Jenna J.
Wheeler, MD
22.00
7.00
4.00
* Signifies statistically significant different percentages of specific cancers diagnosed
at Dayton Children’s compared to nationally.
Jenna Wheeler, MD,
is a PGY3 pediatric
resident at Rainbow
Babies and Children’s Hospital in
Cleveland, Ohio.
She received her
medical school
degree from Wright
State University
Boonshoft School of
Medicine and will
begin a pediatric
critical care medicine
fellowship July 2011.
10
Acknowledgments:
I would like to
thank the following for their
contributions
to this study
and to this
article: Elizabeth Koelker,
tumor registrar;
Adrienne Stolfi,
MSPH; Nancy
Bangert, RN;
John Pascoe,
MD, MPH;
and, Emmett
Broxson, MD.
using a one proportion report for
each diagnosis, hypothesis testing,
calculation of confidence intervals
(CI) and a Bonferroni correction
of our p value for statistical significance (p=0.05/10=0.005). All
hypothesis tests and 95 percent CI
were performed using the NCSS
statistical software.
Table 2
Comparison of childhood cancer data obtained at
Dayton Children’s to that of the national database
% N at DC
95 % Confidence interval
p value
*Wilms tumor
3.49
2.27-5.10
0.0045
*Ewing sarcoma
3.35
2.16-4.94
0.0034
Total leukemia
29.01
25.71-32.48
0.57
Total brain and nervous
system tumors
22.32
19.32-25.54
0.86
Results
Neuroblastoma
5.02
3.54-6.88
0.04
Hodgkin lymphoma
5.02
3.54-6.88
0.18
The occurrence rates for eight of
the 10 cancers studied were found
to be very similar to the national
data, specifically the following:
total leukemia 29.01 percent (95
percent CI: 25.71-32.48, p=0.57);
total brain and nervous system
tumors 22.32 percent (95 percent
CI: 19.32-25.54, p=0.86); neuroblastoma 5.02 percent (95 percent
CI: 3.54-6.88, p=0.04); Hodgkin
lymphoma 5.02 percent (95 percent CI: 3.54-6.88, p=0.18); NHL
3.77 percent (95 percent CI: 2.505.43, p=0.58); rhabdomyosarcoma
2.09 percent (95 percent CI:
1.18-3.43, p=0.16); retinoblastoma 1.81 percent (95 percent CI:
0.97-3.08, p=0.06); and, osteosarcoma 3.07 percent (95 percent CI:
1.93-4.61, p=0.05) (Table 2).
Non-Hodgkin lymphoma
3.77
2.50-5.43
0.58
Osteosarcoma
3.07
1.93-4.61
0.05
Rhabdomyosarcoma
2.09
1.18-3.43
0.16
Retinoblastoma
1.81
0.97-3.08
0.06
Wilms tumor and Ewing sarcoma
both showed a statistically significant difference from the national
occurrence trend. Wilms tumor
occurrence was statistically lower
at DC at 3.49 percent (95 percent
CI: 2.27-5.10, p=0.0045) with
the national percentage being 6.00
percent. It also was found that the
prevalence of Ewing sarcoma was
significantly higher at DC at 3.35
percent (95 percent CI: 2.16-4.94,
p=0.0034) compared with national data of 1.8 percent (Table 2).
Discussion
This study has shown that a statistically significant increased occurrence of Ewing sarcoma exists at
DC. The reason for this increase
is currently unknown and warrants further study to determine a
Type of cancer
* p values <0.005 were considered statistically significant
cause or a commonality between
patients. Such cause may provide
important information to clinicians regarding their patients.
This study also has shown a
statistically significant decreased
rate of Wilms tumor diagnoses,
which corresponds to the mild decrease found via the Surveillance,
Epidemiology and End Results
(SEER) program report including data from 1992-2004. Again,
the reason for this decrease at DC
is unknown and searching for a
cause can provide a subject for
further studies. If a definitive reason is later elicited, it may become
important to clinicians located
at other institutions as a way to
potentially lower their occurrence
rates as well.
References
1. Jemal A, Siegel R, Ward E, et
al. Cancer statistics, 2006. CA: A
Cancer Journal for Clinicians. 2006;
56; 106-130.
2. Steele JR, Wellemeyer AS,
Hansen MJ, et al. Childhood
cancer research network: a North
American pediatric cancer registry.
Cancer Epidemiology Biomarkers &
Prevention. 2006: 15: 1241-1242.
3. Curesearch. Available at http://
nccf.org/our_research/index.
Accessed March 11, 2008.
4. American Cancer Society.
Available at www.cancer.org.
Accessed March 18, 2008.
5. Massey Cancer Center.
Available at www.massey.vcu.edu/
typesofcancer/?pid=1581. Accessed March 18, 2008.
6. Linabery AM and Ross JA.
Trends in childhood cancer incidence in the U.S. Cancer. 2008;
112 (2); 416-432.
CME Questions
11. The overall five-year
survival rate for childhood
cancers is increasing.
a.True
b.False
12. The childhood cancer
type accounting for the
highest percentage of
annual new cancer
diagnoses is leukemia.
a.True
b.False
13. The 1992-2004 SEER
program report demonstrated a decrease in the
number of annual
diagnoses of Wilms tumor.
a.True
b.False
GENETIC TESTING UPDATE: MICROARRAY-BASED
COMPARATIVE GENOMIC HYBRIDIZATION
Objectives
Following the completion of
this article, the reader should
be able to:
1. Describe the essential
difference between standard
FISH and aCGH testing.
2. List two situations where
aCGH testing may be useful.
3. List two situations where
aCGH will not detect an
existing chromosome
abnormality.
Twentieth Century
Cytogenetics
Remember how simple cytogenetic testing used to be? A normal
chromosome test meant a patient
had 46 chromosomes, with either
two Xs or one X and one Y, and
no obvious extra, missing pieces or
rearrangements of those 23 pairs
of chromosomes.
Then came high resolution chromosome analysis—still the gold
standard—and small deletions,
duplications and rearrangements
of 4-10 million base pairs of
DNA were more easily identified. Later on, fluorescence in situ
hybridization (FISH) detected
changes in number of copies of a
specific chromosomal region using
small fluorescently labeled pieces
of DNA from known locations
(probes) that attached to matching DNA in cells or chromosomes
on a slide. The probe stuck to
its matching DNA sequence,
the target, and fluoresce, leaving a glowing spot on the cell or
chromosome where the probe had
found its match. Cells with two
fluorescing spots, or signals, had
two copies of the target DNA,
while a deletion of target DNA
sequence meant only one glowing
signal would be evident. Similarly,
a genetic duplication of the DNA
target produced three probe signals. With FISH, submicroscopic
deletions invisible with standard
cytogenetic banding were suddenly easily detectable. Changes
of 100,000 DNA base pairs were
routinely detected, as long as one
had a probe for the exact target.
Panels of FISH probes designed to
detect the chromosomal subtelomeric regions provided simultaneous detection of the tips of
all the chromosomes to look for
otherwise invisible rearrangements
at the telomeres. Clinical reports
listing dozens of children with
non-syndromic developmental
delays who had submicroscopic
and subtelomeric chromosome
rearrangements excited laboratorians and caregivers alike. Finally,
geneticists began to diagnose some
of those patients with tiny imbalances that had been suspected to
exist but weren’t able to be found!
Fast forward to 2010
Amazing advances in technology
have resulted in the rapid evolution of genetic testing approaches.
New technology allows detection of ever-smaller changes in
the number of copies of DNA.
One of the new tools to emerge
has been microarray technology. A microarray is essentially a
container that allows one specimen—one patient—to undergo
numerous tests all at once. Just as
many kinds of software exist for
different functions of a computer,
different forms of microarray exist
to evaluate different aspects of a
person’s genes such as integrity of
sequence, function, or absence of
a copy as well as to determine the
origin of a tumor, or the genetic
similarities between species. In
the chromosome lab, microarraybased comparative genome
hybridization, more commonly referred to as aCGH, simultaneously
measures the number of DNA
copies at thousands of points
along each chromosome. It’s rather
like performing hundreds of thousands of FISH tests at the same
time. The microarray for aCGH
is collection of thousands of tiny
DNA fragments from individual
chromosomes, like FISH probes,
usually arranged into a grid of tiny
spots on a microscope slide. Very
small changes in the DNA copy
number, down to a few thousand
base pairs of DNA, are detected by
comparing the DNA content of
the patient with a normal control
DNA known to have two copies
of all DNA sequences. The patient
DNA is tagged with a fluorescent
green label, and mixed with an
equal amount of normal control
DNA, which is tagged with a
fluorescent red label. The mixture
is added to the array container,
where the labeled DNA sequences
find and stick to the probe spots
on the array grid. A computerized
scanner measures and records the
amount of red and green fluorescent signal from each spot, matches that data with its chromosomal
origin, and reports a result. Thus,
for each DNA sample, thousands
of FISH-like tests are combined
into one big test.
The aCGH technique is a departure from traditional cytogenetic and FISH approaches, as
no observation of whole cells or
chromosomes occurs. Only pure
copy number gains and losses
will be reliably identified. Clinically important rearrangement of
genetic material, even if it disrupts
gene structure or function, cannot
be identified with this technique,
so standard chromosome analysis
still has an important role to play.
Chromosomal mosaicism, where
some cells change while others do
11
Ruthann
Pfau, PhD
Ruthann Pfau,
PhD, is an ABMG
board-certified
clinical cytogeneticist and genetic
counselor at Dayton
Children’s. She is
an associate professor
of clinical pediatrics at Wright State
University Boonshoft
School of Medicine
and has been with
the department of
medical genetics
for seven years.
12
not, cannot always be identified
with array analysis.
Despite these limitations, aCGH
has dramatically increased identification of genomic copy number
variation among the population of
infants with multiple congenital
anomalies. Additionally, children
with developmental delays and autism with normal high resolution
chromosomes have an increased
frequency of aCGH abnormalities.
In some cases, the genomic copy
number changes are unequivocally
linked to specific developmental
profiles, while in others; children
may inherit these changes from
apparently typical parents. Results
are often framed as normal, likely
pathogenic, likely benign or undetermined significance. Important
to note is a normal aCGH result
ONLY reflects the number of copies present, not the proper function, or even proper structure of
those genes. In general, pathogenic
copy number changes are larger
than 500 kb in size. An estimated
one percent of pathogenic cytogenetic abnormalities such as
low level markers chromosomes,
low-level mosaicism under ~30
percent, or de novo inversions,
translocations or other rearrangements will not be detected with
this new technology.
Interpretations such as normal or
likely pathogenic are fairly straight
forward to explain to families.
However, copy number variation
of uncertain significance is more
challenging to elucidate. Sometimes abbreviated VOUS
or VUS, no reports may exist
of these gains or losses in the
medical literature, either in
normal or syndromic individuals.
Parental evaluation may be helpful, as finding that a typical parent
has the same copy number variant
as the child can be indicative of a
benign change which can be
quite reassuring.
Table 1
Detection Rates of Cytogenomic Abnormalities
aCGH –
Chromosome Fragile Subtelomere Clinically
analysis
X
FISH
significant
Multiple Anomalies/IUGR1
10%
-
-
19%
Non-syndromic MR2
4%
4%
6%
17%
2-4%
2%
low
7%
7%
1%
2%
10%
1.81
0.97-3.08
0.06
Autism Spectrum Disorders3, 4, 5
Developmental Delays, postnatal6, 7
Retinoblastoma
When considering which test to
order, the clinician is faced with
another level of choice: Cytogenomic arrays may be based on
oligonucleotides (Oligo arrays),
single nucleotide polymorphisms
(SNP or snip arrays) or bacterial artificial chromosomes (BAC
arrays, currently less commonly
used). Each of these array platforms has individual strengths and
weaknesses. BAC arrays are less
commonly used because of the
higher resolution oligo and SNP
arrays. SNP arrays have more individual targets, but also may have
a higher frequency of detecting
variations of uncertain significance. SNP arrays can detect some
cases of uniparental disomy, a rare
cause of genomic disease. Consanguinity also may be identified with
a SNP array. Both the 1 M SNP
array with a 5 kb backbone, close
spacing of probes, and the 180 K
oligo array with a 25 kb backbone,
more spread out spacing of probes,
offer overall resolution fairly
equivalent: 50-100 kb resolution
for the SNP array versus 75 kb for
the oligo array. A SNP array analysis often costs more than an oligo
array with similar sensitivity.
Genetic evaluation for MR/
DD and autism is a complicated
process, and while aCGH provides
an excellent tool for diagnosing a
genetic cause in a subpopulation
of these patients, clinicians are
cautioned to consider single gene
testing as well. Single gene traits
such as Fragile X syndrome, Rett
syndrome, and PTEN-associated
macrocephaly/autism syndrome
are caused by genetic changes
involving individual genes. Many
of these changes involve only one
or a few DNA base pairs. These
types of single gene disorders are
not detectable with aCGH.
So, where does this leave the clinician? Considering the increased
sensitivity of the microarray,
some are calling for this test to be
performed before high resolution
chromosomes. Others disagree,
since a higher risk with arrays of
discovering a genomic variant
(copy number change) of uncertain significance exists, necessitating parental array evaluation to
determine whether the change is
hereditary or de novo. Some complexity also exists with so called
susceptibility loci, in which copy
number changes may cause problems in the child, but not in a parent or sibling. Family counseling
with such uncertain information
can be frustrating for clinicians
and families. A major consideration for families is third-party
payor coverage: some payors will
not cover microarray aCGH testing, deeming it investigational. As
the test is currently several times
more expensive than standard
chromosomes, families with high
deductibles or out-of-pocket expenses may be reluctant to pursue
aCGH; preauthorization is recommended. In contrast, cytogenetics
and FISH are less expensive, and
covered by most payors.
At Dayton Children’s, a new
aCGH tool is now available: a
105K oligo array using an internationally standardized design
(International Standardization of
Cytogenomic Arrays, or ISCA).
Current recommendations for utilization of this service in conjunction with chromosome and FISH
testing are as follows:
Standard Chromosome studies:
High index of clinical suspicion
for identifiable syndromes,
such as trisomy 21, 13, 18,
monosomy X; results in 48 hours
for STAT newborns
FISH tests: When specific microdeletion syndromes are suspected
(NOTE: if considering multiple
microdeletion studies and/or
subtelomere FISH, aCGH will be
more sensitive and more economical – order aCGH instead).
High-resolution chromosomes
with reflex to aCGH (when
chromosomes are normal):
multiple anomalies, developmental delay/dysmorphism, pervasive
developmental disorder (also
consider fragile X testing),
idiopathic mental retardation
aCGH: Previous normal chromosome study, or for further characterization of previously detected
chromosome abnormality
Autism study: Fragile X and high
resolution chromosome analysis;
reflex to aCGH if both are normal
Summary
Clinicians have long suspected
that ever-smaller changes in
DNA copy number can and do
exist, and that even tiny changes
may impact human growth and
development. If a single base pair
change (point mutation) can lead
to something as drastic as achondroplasia or Duchenne muscular
dystrophy, larger blocks of DNA
with extra or missing copies can
certainly impact development.
Microarray-based CGH has
provided clinicians with a 21st
century tool with which they can
begin to discern these formerly
elusive genomic imbalances.
aCGH is a valuable technology to aid in the diagnosis of
genomic imbalance or genomic
copy number variation, particularly in cases where symptoms are
non-syndromic or non-specific.
Varying platforms for aCGH have
particular strengths and weaknesses, with oligo arrays offering a
similar sensitivity as SNP arrays,
often at a lower cost.
delays or unexplained/nonsyndromic developmental and or
physical abnormalities.
Ordering aCGH analysis on
patients. This test can be ordered:
4 As a reflex test, to be performed after high resolution
chromosomes are normal, by using
test order code CHROBX.
4 As a stand-alone test, with
previous normal chromosome and
fragile X analysis, by using test
code MACGHB.
References
1. Lu et al. Pediatrics 122 (6):
1310. (2008)
aCGH WILL detect changes of
copy number of specific sequences
of DNA, including gain or loss of
copies of entire genes and parts
of genes.
2. Rauch A, Am J Med Genet A
140A:2063–2074 (2006)
aCGH WILL detect changes
of copy number which MAY
be harmless.
4. Reddy KS, BMC Medical
Genetics 2005, 6:3
aCGH WILL NOT detect
sequence changes or point mutations within individual genes.
aCGH WILL NOT detect
copy number changes of genomic
regions for which no probes exist
on the microarray.
aCGH WILL NOT detect point
mutations or small sequence
changes or copy number changes
below the threshold of resolution,
which can depend on the specific
platform. A lower threshold of detection MAY result in an increase
in detection of copy number
changes of uncertain significance.
When to order aCGH for
patients: Dayton Children’s
medical genetics specialists
recommend aCGH testing in
accordance with published
guidelines for evaluation of
children with developmental
13
3. Yping S, Pediatrics Volume 125:
4, April 2010 e727-e735.
5. Battaglia A Am J Med Genet C
Semin Med Genet. 2006 Feb 15;
Vol. 142C (1), pp. 8-12.
6. Yu S Clin
Genet 2005: 68:
436–441
7. Stankewiecz
P, Current
Opinion in
Genetics &
Development
2007, 17:
182–192
CME Questions
14. aCGH will detect
Single Gene Disorders.
a.True
b.False
15. aCGH can detect
subtelomeric deletions.
a.True
b.False
16. aCGH cannot detect
low-level cytogenetic
mosaicism.
a.True
b.False
17. aCGH can detect balanced
translocations or inversions.
a.True
b.False
14
PROGRAM EVALUATION
1. Did the material presented in this publication meet the mission to enhance
health care delivery in our region through education based on the essentials
and policies of the Accreditation Council for Continuing Medical Education?
c Strongly agree c Agree c Neutral c Disagree c Strongly disagree
Pediatric Forum
Volume 22
Number 2
2. Did the material presented in this publication meet the educational objectives stated?
c Met the stated objectives
c Did not meet the stated objectives
3. Did the material presented in this publication have a commercial bias?
4.
Physician
accreditation
statement
and credit
designation
Wright State
University
(WSU)
Boonshoft
School of
Medicine is accredited by the
Accreditation
Council for
Continuing
Medical Education to provide
continuing
medical education for physicians. WSU
Boonshoft School
of Medicine
designates this
educational activity for a maximum of
2.0 AMA PRA
Category 1
Credit(s)TM.
Physicians should
only claim credit
commensurate
with the extent
of their participation in
the activity.
c Yes
c No
Please rate the contents of this issue using the following scale: 1 = Poor, 2 = Fair, 3 = Good, 4 = Very good, 5 = Excellent
(Circle one response for each.) Poor
Excellent
Timely, up-to-date?
1
2
3
4
5
Practical?
1
2
3
4
5
Relevant to your practice?
1
2
3
4
5
5. Please describe any changes you plan to make in your clinical practice based on the information presented in this program.
_____________________________________________________________________________________________
6. Are there any other topics you would like to have addressed in this publication or future educational programs for health
care providers?
c Yes c No If yes, please describe:_____________________________________________________________
_____________________________________________________________________________________________
7. Please describe how you will incorporate information obtained from this publication into your practice_ ____________
_____________________________________________________________________________________________
8. Letter to the editor (may be published in next issue)_____________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PROGRAM TEST
Your Answers to CME Questions
(Please circle the BEST answer.)
Please type or print clearly
1.
a
b
c
d
Name
2.
a
b
c
d
3.
a
b
c
d
4 Complete the program evaluation.
4.
True
False
4 Return your completed test and
program evaluation by mail or
fax to: Sue Strader, coordinator
Department of Continuing Medical Education
The Children’s Medical Center of Dayton
One Children’s Plaza
Dayton, OH 45404-1815
Fax: 937-641-5931
5.
True
False
6.
True
False
7.
a
b
8.
True
False
9.
True
False
10.
a
b
11. True
False
This sheet must be received by
July 31, 2011 for the credit to be
awarded.
12. True
False
13. True
False
Upon completion of all requirements,
Wright State University will issue a
memorandum of credit to you for
your permanent records.
14. True
False
15. True
False
16. True
False
17. True
False
To obtain CME credit you must:
4 Read and reflect on each article.
4 Answer the questions from each
article and complete this test.
Practice name
Street address
c
City
d
State/Zip code
c
d
e
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Signature
NEWS AND UPDATES FROM DAYTON CHILDREN’S
New specialty services
Behavioral sleep medicine
The Pediatric Sleep Center is
now offering services from Zach
Woessner, PsyD, licensed clinical
psychologist. Dr. Woessner cares
for patients with behavioral sleep
conditions every Tuesday afternoon in the sleep clinic. Behavioral sleep conditions include sleep
association, delayed sleep, bedtime
stalling, nightmares and night
terrors, and more. This service is
for sleep-related issues and is not a
general psychology referral. Referrals are made through the sleep
clinic. Call 937-641-5004 for
more information.
Airway management clinic
We are pleased to announce that
Dayton Children’s, in collaboration with Nationwide Children’s,
is now offering an airway management clinic monthly for children
with airway conditions. These
conditions include bronchomalacia, laryngomalacia, stridor, trach
and ventilator dependents and
more. Clinic is held the second
Friday of every month, with
morning clinic and afternoon
surgical time as needed. Referrals
should be made through pulmonary medicine. Questions?
Call the pulmonary division
at 937-641-3376.
Scoliosis screening
in schools
Starting this fall, Dayton Children’s orthopedic division will
begin assisting area schools with
scoliosis screening. Free screenings will be provided to junior
high school students throughout
the region. Students identified
with possible spine curvature will
be referred to follow up with you,
their primary care physician. We
encourage you to perform a
follow-up screening and if
necessary, refer your patient to a
pediatric orthopedic surgeon.
Call 937-641-3010 for more
information on scoliosis.
Surgery Update
Beginning in September, pediatric
surgery will increase the frequency
of clinics at the Specialty Care
Center - Warren County to weekly. In addition, David P. Meagher,
Jr, MD, will perform surgeries at
Bidwell Surgery Center, conveniently located just behind the
Specialty Care Center. In some
cases, surgeries may be performed
the same day as clinic visits. Refer
your patients through pediatric
surgery, online or by phone at
937-461-5020.
New Infusion Pumps
We are pleased to announce
starting in November,
Dayton Children’s will
implement new “smart
pump” technologies from
CareFusion. These will help
reduce medication errors
during the administration
of intravenous (IV) medications. Smart IV pumps act as an
“assistant” to nurses and clinicians
that administer IV medications
at the point of care. Visit our
website, childrensdayton.org to
see the many ways Dayton
Children’s is committed to
providing the highest standard of
patient safety and quality care.
Home to the only
accredited echo lab
Dayton Children’s is currently
only pediatric echocardiography
laboratory in the Miami region
to achieve accreditation in all
modes of pediatric echocardiography including transthoracic, fetal
and transesophageal. We recently
received accreditation from the
Intersocietal Commission for the
Accreditation of Echocardiography Laboratories (ICAEL) for
transesophageal echocardiography. Refer your patients through
cardiology.
KidsHealth looking for
medical reviewers
KidsHealth (kidshealth.com) is
one of the top websites parents
seek out for information on their
children. Each article on the site
is reviewed by physicians prior
to publishing. Participants may
review as many or little articles as
time allows, and their information
is displayed on the site. If you are
interested in becoming a medical
reviewer for KidsHealth, contact
Moira Alter at 937-641-3618 or
alterm@childrensdayton.org.
15
Dayton
Children’s
welcomes
new
physicians
Yelena Nicholson,
DO, joins us from
the pediatric endocrinology division
at Nationwide
Children’s Hospital.
Dr. Nicholson
completed a fellowship in pediatric
endocrinology at
Winthrop University
Hospital and is board
certified in pediatrics and pediatric
endocrinology. She
has special interest in
diabetes and diabetes
technology including
insulin pumps.
MSO membership
tiers add benefits
Shared Practice Solutions, LLC,
(SPS) is a medical services organization (MSO) supported by Dayton Children’s. The goal of SPS
is to provide high quality, value
added services for primary and
specialty care physician practices
in the community. There are two
levels of participation, with several
discounted services including
insurance, consulting, copying and
medical services. To learn more
about MSO services, visit the
health care professionals section of
our website, childrensdayton.org.
Iris Soliman, MD,
joins us from the
department of
anesthesia and
critical care medicine at the Alfred I.
duPont Hospital
for Children in
Wilmington,
Delaware. Dr.
Soliman is fellowship
trained in pediatric
anesthesia and
intensive care,
regional anesthesia
and acute interventional pain management. She is board
certified in anesthesiology with a special
qualification in pain
management.
Nonprofit Organization
U.S. Postage Paid
Permit Number 323
Dayton, Ohio
16
The Children’s Medical
Center of Dayton
One Children’s Plaza
Dayton, Ohio 45404-1815
KidsCare Link
KidsCare Link is a web-based
program that links you and
your patients’ information to
Dayton Children’s. Lab and
imaging results, consultations
and other notes are available
at your convenience from your
home or office computer. To
request KidsCare Link for your
office or for more information,
contact Ruthie Laux or Kim
Grant, physician relations
managers, at 937-641-3498.
The Right Care
for the Right Reasons
Dayton Children’s website has
a brand new look
As your pediatric experts,
we’ve redesigned our website
with you in mind.
Find a doctor, get directions,
CME or learn more about
your patients’ health.
childrensdayton.org/cms/provider