New technique treats irregular heartbeats and lessens radiation exposure The Children's Hospital of Michigan's pediatric experts are treating patients with irregular heartbeats using a relatively new technique - no radiation ablation (also known as no fluoroscopic guidance) - distinguishing Children's as the only pediatric hospital in the state using the technique. Only a handful of other hospitals in the country currently use no radiation ablation. This technique has zero side effects of radiation exposure to the patient, caregiver and personnel in the laboratory. For patients requiring multiple treatments over time and for the caregivers providing the treatment, this is positive news. Irregular or rapid heartbeats can occur in healthy kids without causing any dangerous symptoms or requiring medical attention, and the condition is fairly common according to Children's Hospital of Michigan Pediatric Electrophysiologist  Harinder Singh, M.D. "Three in every 1,000 kids may have Wolff-Parkinson-White syndrome, and 1 in 100 may experience Supraventricular tachycardia (SVT)," he says. Slight changes in the normal patterns of heartbeats can often reset themselves without notice. "But when the heartbeat is greatly disrupted, either because of abnormal electrical connections, genetic conditions, previous heart surgeries or heart muscle diseases, the condition must be recognized and treated immediately as some types of fast heart rhythms can even be fatal," Singh cautions. Prior to no radiation ablation, catheter ablation was performed in the cardiac catheterization laboratory using fluoroscopic guidance to correct a disturbance in heart rhythm. This technique exposed patients and caregivers to low levels of radiation each time the procedure was conducted. Cumulative exposure to radiation can cause damage to living tissue, resulting in skin burns, radiation sickness and death at high doses, and cancer, tumors and genetic damage at low doses. Since last year, doctors at the Children's Hospital of Michigan have performed catheter ablations using the no radiation ablation technique to treat irregular or rapid heartbeats. They've found no change in the success rate, complications or durations with no radiation ablation, as compared to the use of fluoroscopic guidance. The procedure is also safe for pregnant females and their unborn babies. Last reviewed: December 2010 Children’s Hospital Researcher Develops New Brain-Mapping Technique Eishi Asano, M.D., Ph.D., didn’t pursue years of advanced neurosurgical, neuroimaging and neurophysiology training to make animated videos for kids. But a novel animation technique he developed is generating significant attention in the worldwide neurodiagnostic community. Dr. Asano is studying an advanced neurodiagnostic technique called "in-vivo animation of event-related gamma-oscillations." It’s a new, brain-mapping technique that enables neurosurgeons to identify and avoid areas of the brain that control language and listening skills. Results of his initial research have been published in prestigious medical journals, including Brain and NeuroImage. Dr. Asano believes his new technique will result in better outcomes for children undergoing neurosurgical procedures to remove brain tumors and epileptic foci. The National Institutes of Health (NIH) shares his enthusiasm and is funding his research with a $1.1 million grant. The Current Technique: Electrical Stimulation Using current neurodiagnostic techniques, the language centers of the brain are extremely difficult to pinpoint in children. "Currently, the gold standard is stimulating a patient’s brain by electrical current. If the patient cannot talk during stimulation of a particular area, then we can say that those areas are responsible for language," said Dr. Asano, Medical Director of Neurodiagnostics at the Children’s Hospital of Michigan. It’s a fairly crude way of identifying delicate areas of the brain. The current test lasts from one to two hours, which can be exhausting for young patients. And it’s not very effective in children under the age of 10. In addition, electrical stimulation sometimes causes seizures. The New Technique: Mapping Gamma Oscillations Thanks to new EEG technologies, neurodiagnostic specialists can now identify extremely fast brain waves called "gamma oscillations." In 2008, Dr. Asano read a paper describing a technique using gamma oscillations to precisely map areas of the brain that control motor skills in adults. He immediately knew the technique had important implications for pediatric neurosurgery. That’s when he began developing his advanced animation technique that translates the gamma oscillations on an EEG into animated clusters of activity on a map of the patient’s brain. The patient simply answers about 50 questions while the computerized animation system shows the precise areas of the brain where gamma oscillations occur. These are the language and listening centers of the brain — areas to avoid during surgery. The new technique offers many advantages over the current diagnostic approach. It takes only five minutes compared to one or two hours. There is no risk of creating seizures in the patient. The new technique is more precise than the current test, especially in children. Dr. Asano and his colleagues at Children’s Hospital will continue testing and refining the animation technique as part of the NIH-funded research. "We hope this will be the new standard for children someday," he said. "We have a lot of work to clinically validate it, but it’s a very promising technique." Last reviewed: December 2010 Pediatric Anesthesia and Clinical Systems Teams Work Together to Improve EMR When preparing for surgery, pediatric anesthesiologists need to review specific details from the patient’s medical record — current medications, previous surgical procedures, lab results and much more. Since DMC Children’s Hospital of Michigan is among the nation’s leaders in Electronic Medical Records (EMR), you might think this would be an easy task. "We used to have a single sheet of paper with all this information on it. We used this information to develop an anesthesia plan for each patient," said Maria Zestos, M.D., Chief of Pediatric Anesthesiology at the Children’s Hospital of Michigan. "Unfortunately, it takes a very long time to find all this information in the EMR." In fact, the required data is located in at least 12 different sections of the patient's EMR and requires more than 30 mouse clicks to access. It was enough to make many pediatric anesthesiologists miss the old, paper-based system."EMR is a powerful tool offering us a wealth of patient information, but accessing that information can be challenging," Dr. Zestos said. "Every clinician needs to review different data elements and the system just didn’t meet our needs very well." With dozens of different specialists and subspecialists across the DMC — each needing to access slightly different subsets of patient data — it's hard to imagine a single system that meets everyone's needs perfectly. "We’ve spent the last five years working with physicians to get their documentation into the system so everything we have is electronic," said Paula Tank, Director of Clinical Systems at the DMC. "But what we’ve found is that getting the data back out has been an issue." This is why DMC CEO Mike Duggan created a process for identifying, prioritizing and funding EMR enhancement projects: the EMR Improvement Award. "We're constantly working to improve and enhance the EMR," Paula said. "When a specific need is identified, when a specific project can significantly improve efficiency and patient care, that's when it might merit the special attention and funding of an EMR award."  The Department of Clinical Systems proposed a solution — creating a customized EMR view page for the Pediatric Anesthesia team. This "Pediatric Anesthesia Summary Page" would automatically pull selected data from far-flung corners of the EMR and bring it all together on a single screen. The project was nominated for an EMR award. According to Paula Tank, programming the solution was fairly easy. Identifying the specific data to be included in the summary view was more challenging. "We need to have a high level of specificity in developing our data requirements," Paula said. "And that’s usually not the way people think." An example: A physician might say they need to see the patient’s CBC results. But a complete blood count includes about a dozen different data elements. "It might turn out that all they really want to see is the patient’s white blood cell count or the hemoglobin level," Paula said. "We’ve learned that developing a solution like this tends to be an iterative process. You develop something, you get feedback from the clinicians and then you go back and fine tune it. That seems to be the process that works best."  After six months of work and several revisions, the Pediatric Anesthesia team at the Children’s Hospital of Michigan began using the new summary page in September 2010. "We are just thrilled with the result," Dr. Zestos said. "Now we can pull up the information we need with just one click of the mouse. And it’s not just information from the current admission. We can see data across previous encounters too." Based on the success of the Pediatric Anesthesia Summary Page, the Clinical Systems team is now working on a similar summary page for Anesthesia Departments at other DMC hospitals. Last reviewed: December 2010 Division of Genetic and Metabolic Disorders Plays Important Role in Michigan’s Newborn Screening Program It starts with a pin prick and a drop of blood on a piece of filter paper. The State of Michigan requires every newborn to be screened for a panel of genetic disorders and other conditions. Of the approximately 116,000 infants born in Michigan in 2009, 99.5% were screened through the state’s Newborn Screening program — and the Children’s Hospital of Michigan plays an important role in the process. "The rationale is quite simple: If there’s a disorder that can be identified and treated before symptoms develop, then it makes sense to screen for it when an infant is first born," said Gerald L. Feldman, M.D., Ph.D., FACMG, Director of Clinical Genetics Services and the Newborn Screening Management Program at the Children’s Hospital of Michigan.   All newborn screening cards in Michigan are sent to the state’s Newborn Screening Laboratory in Lansing. The blood samples are then screened for 49 different disorders — everything from phenylketonuria (PKU) and rare genetic disorders like maple syrup urine disease (MSUD) to more common conditions like sickle cell anemia and cystic fibrosis. When the state laboratory suspects an inborn error of metabolism in a newborn, they immediately notify the Newborn Screening Program at the Children’s Hospital of Michigan, part of the hospital’s Division of Genetic and Metabolic Disorders. Dr. Feldman and his team at Children’s Hospital then follow up with the infant’s family and primary care physician to confirm the diagnosis and begin the appropriate treatment. For other disorders, such as sickle cell anemia or cystic fibrosis, the patients are referred to other specialists at the Children’s Hospital of Michigan for further testing and treatment. "Whether a child is born in the Upper Peninsula, Grand Rapids or the Metro Detroit area, they are referred to the Children’s Hospital of Michigan for confirmation of a positive screen," Dr. Feldman said. "Of course, not all of the infants referred to us actually turn out to have an inherited metabolic disorder. The initial test is just a screen, so there are occasional false positives." For example, 124 positive screens were referred to Dr. Feldman’s team for confirmation in 2009. Of those, 78 were confirmed as inborn errors of metabolism. The state chose to centralize confirmation and management of genetic and metabolic disorders at the Children’s Hospital of Michigan in 2004, the same year Michigan adopted national recommendations to screen for 49 different disorders instead of just the 11 that were then screened in Michigan. According to Dr. Feldman, the state made the decision on the basis of recommendations made by a national newborn screening site visit committee. At that time, the Children’s Hospital of Michigan was the state’s only full-service, free-standing pediatric hospital with board certified specialists in biochemical genetics and a multidisciplinary team of metabolic specialists. "More than just confirming disorders, we manage care for these infants," Dr. Feldman said. "Ultimately, our goal is to treat patients before symptoms develop and that sometimes requires hospitalization to prevent patients from progressing to a life-threatening situation." The Newborn Screening Program at the Children’s Hospital of Michigan offers a multidisciplinary approach to patient care. In addition to board certified specialists in metabolic disease, the program is staffed by specially trained metabolic dietitians, nurse practitioners, nurses, a clinical psychologist, a social worker and a genetic counselor. "Our patients are evaluated by all of our team, as needed," Dr. Feldman said. "That’s a big difference in our program versus what might be offered in other states." While the Children’s Hospital of Michigan is a pediatric specialty hospital, management of patients with inborn errors of metabolism is lifelong. "Come to our clinic and you’ll see infants as well as patients who are 40 years old," Dr. Feldman said.   Newborn Screening Saves Lives In 2004, a family in Ypsilanti welcomed a newborn boy into the world. Within a few days, the mother realized the infant was having trouble feeding. The family pediatrician understandably thought it was a routine newborn issue. But, miles away in the state Newborn Screening Lab, that little piece of filter paper told a different story. The screening was positive for Maple Syrup Urine Disease (MSUD), a rare metabolic disorder in which the body cannot break down certain amino acids. Left untreated it can cause acute illness, neurological problems, coma and even death. Recognizing feeding problems as one of the early symptoms of a metabolic disease, Dr. Feldman’s team at the Children’s Hospital of Michigan immediately contacted the family and arranged confirmatory testing, hospitalization and management of the disorder — all before life-threatening symptoms developed. "This is a good example of how newborn screening saves lives," Dr. Feldman said. Last reviewed: December 2010 Breakthrough in Tourette Syndrome Research Groundbreaking research done by a team of neurologists and geneticists led by Ahm Huq, M.D., Ph.D., FRCPC, Senthil Sundaram, M.D. and Children's Hospital of Michigan Chief of Neurology, Harry Chugani, M.D. identified the genetic abnormalities in some  patients with Tourette syndrome. The landmark study was published in the May 2010 issue of Neurology, with an important introduction by the journal's editorial staff. This innovative work is the direct result of the generosity of Bruce and Rosalie Rosen, who established the Wayne State University Rosalie and Bruce Rosen Family Chair for Tourette Syndrome and Related Neurological Disorders Research. Chugani is the incumbent of this Chair, which has enabled him to focus on improving the care of children with neurological disorders, specifically Tourette syndrome. The Children's Hospital of Michigan is one of approximately eight centers in the country currently investigating multiple aspects of Tourette syndrome and is considered a national leader in the field. Last reviewed: December 2010
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