Medical News – Holiday 2019

Behavioral Health Transitions Clinic

As January approaches, so does the one-year anniversary of the Emergency Department Behavioral Health Transitions Clinic, which has provided our emergency department patients with behavioral health concerns a critical service.

This clinic was opened on January 21, 2019 with the goal of bridging a gap between the ED and community behavioral health providers, primary care providers and schools. Psychiatry, social work and care coordination have been brought together at this clinic to decrease the amount of unnecessary hours and even days spent in the ED for many patients. Patients with psychiatric diagnoses who can only be safely discharged from the ED if they have immediate access to a psychiatric provider can be seen in the Transitions Clinic in 1-3 days.

During the first visit, the patient and family are offered services including individual or family therapy, short-term medication management and care coordination. Our social workers and psychiatrist provide the patient and their families the proper short-term treatment they need to ensure a safe and timely transition back to community based providers. Staff from the Center for Care Coordination at Connecticut Children’s work within the clinic to help the families and the clinical team ensure connection to the appropriate community services, identify any other available community-based resources, and provide on-going support beyond their short-term care in the clinic.

This service is currently only being offered to ED patients who would otherwise experience long waits in the ED for community treatment/services. We are working to expand the capacity of the Transitions clinic to ensure that all of our patients have access to the care they need, when they need it.

Convenience is Crucial with the Connecticut Children’s Mobile App

This December, Connecticut Children’s is excited to launch the new, patient-focused mobile app that will provide digital support for our patient/family’s healthcare journey.

Fairfield County-Focused Pediatric Community: Referring Provider Advisory Board

Connecticut Children’s is proud to announce the official launch of a network of Fairfield County pediatricians who have formed two enthusiastic Referring Provider Advisory Boards (RPABs) for Northern and Southern Fairfield County.

Medical Director of Physician Relations for Fairfield County, Robyn Matloff, MD, MPH, and physician liaison, Janeille Ervin, spearhead this initiative in effort to engage with community pediatricians in the southern part of the state and allow for more engagement with Connecticut Children’s.

Bruce Cohen, MD, co-chairs RPAB-North, while Jeffrey Owens, MD, co-chairs RPAB-South. When discussing the overall goals, Dr. Matloff says, “by having locals on the board, we can best see what their challenges are and hear all feedback as we try to make sure that all needs are met.”

With the ultimate goal of improving access and care to children locally by bringing expert care from Hartford to all of Fairfield County, Connecticut Children’s will continue working in collaboration with Danbury and Norwalk Hospitals.

Connecticut Children’s Inpatient Services at Danbury, Norwalk and St. Mary’s Hospitals

For children in the Fairfield and New Haven county region, Connecticut Children’s offers inpatient services at Danbury, Norwalk and St. Mary’s Hospitals for patients who are stable and do not require emergent intervention.

The Season for Precaution: What You Need to Know About the Flu

Melissa Held, MD of Connecticut Children's Infectious Diseases & Immunology department shares tips for preventing and treating influenza.

It is that time of year again—time to think about the FLU. Influenza or commonly called “the flu” is a contagious respiratory illness caused by influenza viruses. There are two main types of influenza virus that include Influenza type A and Influenza type B. Some people, such as young children, the elderly and those with underlying medical conditions are at higher risk of complications from influenza. Symptoms vary but often include fever, chills, body aches, headaches, cough, sore throat, runny nose, nasal congestion, fatigue and general malaise. Children may also have vomiting and diarrhea. Complications from influenza may include bacterial pneumonia, otitis media, sinusitis, parotitis, worsening of underlying medical issues such as asthma or diabetes, and, rarely, death.

The first and most important step in preventing influenza infection is vaccination. Routine annual vaccination of all persons aged >6 months (who do not have other contraindications) continues to be recommended for the 2019-2020 season. Given the unpredictable nature of the influenza season, vaccinations became available at the end of October, but can be given at any time during the season. Vaccination should be offered during routine and other health care visits. There are several options for vaccination for the 2019-2020 season including the quadrivalent (4 strain), Live attenuated influenza vaccine (LAIV), recombinant, along with several recommended for older adults.

There are several ways to diagnose influenza. Decisions on whether to test should be based on signs, symptoms, age, underlying medical issues and other epidemiologic factors. Confirmation of influenza virus infection by diagnostic testing is not required for decisions to prescribe antiviral medication. Influenza testing may help with infection control and prevention practices and may aid in limiting additional testing or use of unnecessary antibiotics. If testing is undertaken, the Infectious Diseases Society of America (IDSA) recommends use of rapid influenza molecular assays over rapid influenza diagnostic tests (RIDTs) for detection of influenza viruses in respiratory specimens of outpatients. RIDTs have limited sensitivities, however, and so a negative test may not exclude influenza infection if a patient has signs and symptoms consistent with influenza. Once influenza activity has been documented in an area, testing is not needed for all patients with signs and symptoms consistent with influenza. Overtesting in the urgent care setting is discouraged. It is important to remember that the positive predictive value of an RIDT (the proportion of patients with positive results who have influenza) is highest when influenza activity is high in the population being tested (e.g. community).

Antiviral treatment is recommended as soon as possible for any patient with suspected or confirmed influenza who is at particular risk of complication. There are four FDA-approved antiviral drugs recommended by CDC to treat influenza and include: oseltamavir phosphate (Tamiflu®), zanamavir (Relenza®), peramivir (Rapivab®) and baloxavir marboxil (Xofluza®). Generic oseltamivir and Tamiflu are available in pill or liquid suspension and are FDA approved for early treatment of flu in patients 2 weeks old and older. Oseltamivir is the primary medication prescribed for children and side effects may include headache, nausea or vomiting. Rarely, use of oseltamivir has been associated with neuropsychiatric symptoms (such as hallucinations) in pediatric patients from postmarketing surveillance. Ideally, treatment should begin within 48 hours of illness onset.

For more information on influenza symptoms, diagnosis, testing and treatment, visit the CDC website.

Learn more about Dr. Held

Updated Imaging Services at Connecticut Children’s

The Department of Radiology has seen a major upgrade in its imaging equipment over the past several years.

Routine imaging is performed with digital radiography, which allows for better plain film imaging with approximately 40 percent less radiation than conventional radiography. First in the state, our low-dose EOS Imaging System is located in the Connecticut Children’s Orthopedic Surgery location at 31 Seymour St in Hartford. This system provides ultra-low-dose, 3-D weight-bearing scans to clearly evaluate spinal and lower extremity alignment. The technology helps to reduce the radiation dose for patients who may need to undergo repeated imaging tests. It also allows better ease and comfort in positioning patients who may have physical impairments.

The Ultrasound division now offers extended appointments at our Hartford campus on both weekdays and weekends. Ultrasound has also been expanded to our Danbury facility, allowing the community greater access to expertly performed examinations by our subspecialty trained sonographers. State-of-the-art ultrasound equipment introduces advanced techniques to our pediatric patients. Shear wave liver elastography can noninvasively screen for liver fibrosis. Contrast-enhanced ultrasound using microsphere bubbles assists our radiologists in the evaluation of vesicoureteral reflux or characterization of lesions in the liver without the need for radiation or sedation.

Fluoroscopy is performed at the 282 Washington St location in Hartford using a Siemens flat-panel fluoroscopy unit with pulsed fluoroscopy, allowing for significant radiation dose reduction with improved image quality. This equipment is in alignment with our philosophy to “Image Gently and Step Lightly” to provide appropriate imaging while reducing as much as possible exposure to ionizing radiation. To increase the availability of services, we have added staff and are installing a second fluoroscopy unit. In 2020, our portable CT scanner will be upgraded to a 16 slice Omnitom to provide faster scan times, a smaller footprint and better maneuverability, and immediate access to image review, leading to faster results for critically ill patients. We continually monitor our CT scanning techniques to ensure dose optimization for children. When feasible, the techniques are modified to allow imaging without the need for sedation or general anesthesia. For more technically challenging or lengthy studies and procedures, the Sedation Service, Anesthesia Services, and the Child Life Team offer outstanding resources to help our children undergo the examinations.

The MRI department has undergone a major technological and facilities renovation and now offers imaging with a 1.5T and a 3T field strength scanner at Connecticut Children’s Hartford Campus. The installation of a new 3T MRI system expands our onsite imaging capabilities with the addition of advanced cardiac imaging and neuroimaging (functional imaging, diffusion tensor imaging, and perfusion imaging of the brain). We are also excited to offer Siemens LiverLab imaging (hepatic fat and iron quantification), MRI elastography, and improved dynamic contrast-enhanced body imaging with our new expansion. Advances in whole body imaging, vascular imaging, and faster scan times are also anticipated in the future. The MRI suite has been renovated for improvement in workflow and patient experiences. With over 175 child friendly movies as well as music selections, children can often undergo their MRI scan comfortably without sedation, and can be accompanied by the parents during the scan. We continue to work hard to improve scan times and decrease the need for sedation using a multidisciplinary approach.

Case Review: Not So Harmless

John Brancato, MD of Connecticut Children's Emergency Department shares the case of a 7-year-old boy who visited the ED with altered mental status.

An almost 8-year old male was presented to the Connecticut Children’s Emergency Department by EMS with altered mental status. He had been seen in the ED several weeks earlier after hitting his head on exercise equipment. A forehead laceration was sutured at that time and he was discharged. On the day of presentation, the patient had been playing in the yard after dinner when he began acting strangely. He walked back into the house, bumping into a sliding door. He complained of dizziness and that his head felt ‘full’. He vomited once then became pale, shaky and slumped to the floor. His finger stick glucose checked by EMS was 125 and he was brought for evaluation. He had no incontinence nor clear seizure activity. He had had no fever, known exposures or trauma.

In the ED, he was lethargic and diaphoretic. His temperature was 37.6, heart rate 132, respiratory rate 26, blood pressure 115/72 and oxygen saturation 100%. His head was atraumatic and his neck was supple. His pupils were 7mm and equal, reactive. He was responsive to voice and was tachycardic, but without other focal findings.

An extensive workup was initiated, during which he was administered a bolus of normal saline. Besides a potassium of 3.2 mmol/L, glucose of 193 mg/dL and BUN of 23 mg/dL, his work up was negative/normal, including head CT, venous blood gas, complete blood counts, urinalysis and serum ammonia. He was admitted for further evaluation on the Neurology service.

On the morning after admission, he had improved mentation and urine was sent for toxicologic screening. A positive result for cannabinoid metabolite (193 ng/mL) was obtained. On further questioning, the patient’s father disclosed that he had a prescription for medical marijuana ‘gummies’ and the patient confirmed that he had ingested some of the substance.

The United Nations estimates that approximately 159 million people or 3.8% of the world population use cannabis, the most widely cultivated, trafficked and abused illicit substance(1). Its use among U.S. adolescents is significant, as almost 6% of 8th graders and 23% of 12th graders reported cannabis use in the past month. The association between legalization and unintentional pediatric ingestions has been documented. After Colorado legalized cannabis, calls to the regional poison control center regarding pediatric marijuana exposure increased 34% to 6 per 100,000 population, almost twice the national average(2).

Compared to inhaled cannabis, the onset of psychomotor effects of ingested cannabis is delayed, ranging from 30 minutes to 3 hours. Effects may last up to 12 hours. First time users may experience effects with 5 to 20 mg of THC (delta-9 tetrahydrocannabinol). Symptoms may include sleepiness, behavior changes, nausea, vomiting, conjunctival injection, ataxia, hyperkinesis (abnormally increased and sometimes uncontrolled muscle movements), respiratory depression and coma. In a 2016 study, estimated THC dose was associated with greater medical intervention3. Ingestion of 3.2 mg/kg required observation, 7.2 mg/kg led to admission and moderate intervention, and 13 mg/kg of THC led to intensive care unit admission and major intervention.

Standard urine drug screens use immunoassays to assess for THC metabolites. False positive results are rare. Thus, in a young child, any positive result identifies acute exposure. While urine studies may remain positive for several days after an acute exposure, they may also demonstrate THC for 10 days to 3 weeks after chronic use, not providing useful information on timeline or severity of exposure.

Management of acute exposure is supportive. Blood glucose is assessed to exclude hypoglycemia; supplemental oxygen and airway protection are indicated for patients with significant respiratory or mental status depression. Benzodiazepines may be used for severe agitation.

  1. World Drug Report 2016. United Nations Office on Drugs
    and Crime. http://www.unodc.org/wdr2016/en/cannabis.
    htm. (Accessed on 13 Nov 2019)
  2. Wang GS et al. Unintentional Pediatric Exposures to Marijuana
    in Colorado, 2009-2015. JAMA Pediatr 2016; 17:e160971.
  3. Heizer JW et al. Marijuana Misadventures in Children: Exploration
    of a Dose-Response Relationship and Summary of Clinical
    Events and Outcomes. Ped Emerg Care 2018 Jul;34(7):
    457-462.

Pediatric-Specific Value-Based Contracts—Connecticut Children’s Care Network

The Connecticut Children’s Care Network has had a productive and successful year. Independent community pediatricians have dedicated countless hours to develop the state’s only pediatric specific integrated care network.

From the governance board to the finance, quality, and membership committees, each member shows an inspiring level of commitment to improve care on a variety of levels. The Care Network is defining value in pediatrics, aiming to both improve the quality of care and decrease unnecessary costs.

The pediatric-specific value-based contracts negotiated by the network reward community pediatricians, specialists, and the hospital for working together to improve child health. In addition, the network works together as a pediatric community to advocate for children and their families.

The network’s quality committee is composed of community pediatricians, specialists, care coordinators, data analysts and quality improvement personnel who carefully review the metrics the network should focus on to improve care. More importantly, the committee has worked to develop a core set of pediatric-specific measures that inform insurance companies of important outcomes in children’s healthcare. In multiple cases, the network has worked with insurance companies to remove measures that the committee felt don’t improve quality of care for children, illustrating the importance of working collaboratively.

The network includes a quality improvement team that works with practices closely to help them improve their performance on their metrics and support their ability to manage their patient panel. This team will provide performance reports and host learning communities, which allow community providers come together to share best practices, while providing CME and MOC credits. Moreover, they have access to a nationally recognized center for care coordination, specialists, behavioral health partners and community programs through the Office for Community Child Health.

Graham’s Foundation Recognizes James Moore, MD, PhD

James Moore, MD, PhD, division head for Neonatal-Perinatal Medicine at Connecticut Children’s was honored by Graham’s Foundation.

Graham’s Foundation is the global support organization for families facing the challenges of premature birth. Dr. Moore was honored at its ‘Tinis for Preemies event at the Upper Story by Charlie Palmer in New York on November 7th. Please join us in congratulating Dr. Moore in this accomplishment and his leadership in neonatal care.

Connecticut Children’s Welcomes Director of Oral and Maxillofacial Surgery

Connecticut Children’s is pleased to welcome Stuart Lieblich, MD, as the new Director of Oral and Maxillofacial Surgery.

Dr. Lieblich is a partner at Avon Oral, Facial, and Implant Surgery and has been a part of Connecticut Children’s medical staff for 23 years. He made a large impact on improving lives with his expertise in oral surgery. Please join us in welcoming Dr. Lieblich to his new role!

Donna Zeiter, MD, Returns to Connecticut Children’s as the new Medical Director of Physician Relations for Western Massachusetts

Please join us in welcoming back Donna Zeiter, MD, to Connecticut Children’s as a Pediatric Gastroenterologist and the Medical Director of Physician Relations for Western Massachusetts.

Dr. Zeiter is excited to help lead the initiative to expand our care up north by providing multiple subspecialties at our new satellite clinic at 84 Willimansett Street in South Hadley, Massachusetts. Dr. Zeiter knows Connecticut Children’s very well as she was previously a beloved member of the Division of Pediatric Gastroenterology and Nutrition for more than 20 years. She is excited to rejoin an organization she finds to be thoroughly committed to the care of children and adolescents.

Glenn Flores, MD, Recognized by the American Public Health Association

We’re thrilled to share that Glenn Flores, MD, FAAP, will receive this year’s David P. Rall Award for Advocacy in Public Health from the American Public Health Association (APHA).

New Leadership Announcements

We are welcoming new faces and congratulating others for significant accomplishments!

Following an extensive national search, we are happy to announce that Michele R. McKee, MD, MS, FAAP has been appointed the new Division Head of Emergency Medicine at Connecticut Children’s and the Department of Pediatrics at the University of Connecticut School of Medicine.

Congratulations to Barbara Edelheit, MD, who was recently appointed Division Head of Rheumatology, effective October 1. Her leadership will continue to strengthen and enhance our state-of-the-art clinical services; and help to develop a clinical research program in rheumatology.

Alyssa Bennett, MD, the current Division Head for Adolescent Medicine at Connecticut Children’s, has been named the inaugural holder of The Burton and Phyllis Hoffman Family Endowed Chair in Adolescent Medicine. A native of the Northeast Kingdom of Vermont, Dr. Bennett earned a BA in chemistry from Skidmore College and is a graduate of the Robert Larner, MD College of Medicine at the University of Vermont. She completed her pediatrics residency at the University of Connecticut School of Medicine and a fellowship in adolescent medicine at Boston Children’s Hospital.

Welcome Aboard!

We're pleased to announce these new additions to our medical staff.

Caroline DeBenedictis, MD
Ophthalmology

  • MD, Jefferson Medical College
  • Residency in Internal Medicine at Pennsylvania Hospital
  • Residency in Ophthalmology at North Shore-LIJ Hospital
  • Chief Resident at North Shore-LIJ Hospital
  • Fellowship in Pediatric Ophthalmology & Strabismus at Wills Eye Hospital

Hareem Park, MD
Hospital Medicine

  • MD, New York Medical College
  • Residency, Children’s Hospital of Philadelphia

Amy Hughes, MD
Otolaryngology

  • MD, Loyola University Stitch School
    of Medicine
  • Residency at University of Connecticut
    Health Center
  • Fellowship in Pediatric Otolaryngology
    at Boston Children’s Hospital

John Schreiber, MD, MPH
Infectious Diseases

  • MD, Tulane University School of Medicine
  • Residency in Pediatrics at Boston Children’s Hospital
  • Fellowship in Pediatric Infectious Diseases
    at Boston Children’s Hospital
  • Fellowship in Clinical Neurophysiology at Drexel University/Hahnemann Hospital

Ashley Notartomaso, MD
Emergency Medicine

  • MD, St. George’s University School
    of Medicine
  • Residency in Pediatrics at St. Joseph’s Regional Medical Center
  • Chief Resident in Pediatrics at St. Joseph’s Regional Medical Center
  • Fellowship in Pediatric Emergency Medicine at Baystate Medical Center

Willliam Yorns, DO
Neurology

  • DO, Philadelphia College of Osteopathic Medicine
  • Residency in Pediatrics at Connecticut Children’s Medical Center
  • Fellowship in Pediatric Neurology at
    St. Christopher’s Hospital for Children
  • Fellowship in Pediatric Neurophysiology
    at Drexel University

Chinyere Okoronkwo, MD
Primary Care

  • MD, St. George’s University School
    of Medicine
  • Residency at Albany Medical Center

Donna Zeiter, MD
Gastroenterology

  • MD, The Johns Hopkins School
    of Medicine
  • Residency at The Johns Hopkins
    School of Medicine
  • Fellowship at Children’s Hospital
    of Philadelphia

 

New Wayfinding Murals

Over the past year, Connecticut Children’s has worked to unify the look and feel of all of our physical spaces. Each floor has a theme designation, with murals designed by a Connecticut-based graphic artist, which facilitates with wayfinding for patient and family navigation.

The Curbside Consult Podcast

Subscribe to the new Connecticut Children’s podcast, The Curbside Consult, to hear from our experienced specialists on a variety of topics.

Physicians from Rheumatology, Sleep Medicine, Cardiology, Hematology/Oncology, Adolescent Medicine and more have joined Patricia Garcia, MD, MPH, to discuss specific cases, new research and valuable information for pediatricians, patients and families. The Curbside Consult is available to you now on Apple Podcast, Spotify and Google Play.

Save the Date 3rd Annual Joint Pediatric Symposium

Join us for our 3rd Annual Joint Pediatric Symposium in June 2020 at Danbury Hospital.

Friday, June 5, 2020

7:30-8:00am               Registration/Opening Remarks

8:15am-12:30pm        Morning Session

12:30-1:30pm             Lunch

1:30-3:30pm               Afternoon Session

3:30-3:45pm               Closing Remarks

Location:

Creasy Auditorium, Danbury Hospital
24 Hospital Ave, Danbury, CT

Target Audience:

Pediatricians, Family Practitioners, APRNs, Physician Assistants, Nurses, and Medical Students

Objective:

  1. Develop new skill sets based on recent pediatric
    advances in a wide spread variety of specialties
  2. Identify evidence-based data to support improved
    outcomes in pediatric healthcare delivery
  3. Improve the management of a variety of diseases
    with implications for clinical practice

For all CME events, stay up to date by visiting our calendar at cccme.eeds.com

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