pediatric - Children`s Hospital of Michigan

pediatric
E X P E R T S & I N N OVAT I O N S
DMC Children’s Hospital of Michigan • Fall 2012
Pediatric Burn Treatment
Seven-year-old girl with severe burns treated
with Cultured Epidermal Autografts (CEAs) –
skin grafts grown in a laboratory from her own cells
Read more on page 2
pediatric burn treatment
CA S E S T U DY
Pediatric Patient with
Severe Burns Treated with Epicel
Cultured Epidermal Autografts (CEAs)
®
A 7-year-old female recently presented
at the Children’s Hospital of Michigan Burn
Center with full-thickness burns on more than
60 percent of her body – including her legs,
abdomen, buttocks, back, face and one arm.
Due to the severity and extent of her burns, the
Burn Center staff almost immediately knew
Christina Shanti, M.D.
that split-thickness autografts would not be a
sufficient treatment option; the patient simply didn’t have enough of
her own undamaged skin to cover the burned portions of her body.
Instead, Christina Shanti, M.D., Director of the Burn Center, and
her team focused on stabilizing the patient and preparing her for
treatment with Cultured Epidermal Autografts (CEAs) produced
under the brand name EPICEL®– skin grafts that are grown in a
laboratory from the patient’s own skin cells. EPICEL is approved by
the FDA as a humanitarian use device (HUD), but it has been used
in only about 1,500 patients during the last 25 years.
C A S E S T U DY
same time, a full-thickness skin biopsy about the size of a postage
stamp was taken from a healthy, unburned section of her skin.
The biopsy was then sent to the Genzyme Corporation in Boston,
the creators of the EPICEL process. At Genzyme, a team of specially
trained technicians extracted skin cells, called keratinocytes,
from the biopsy and combined them with animal skin cells using
a biological process that takes between 16 and 21 days. In just a
few weeks, enough EPICEL can be grown to cover an entire adult
body. Each EPICEL graft is approximately the size and shape of a
playing card. When the EPICEL was ready, it was hand-delivered
by a Genzyme representative to the Children’s Hospital of Michigan
Burn Center operating room, immediately before the scheduled
surgery for application/grafting.
In preparation for the Epicel treatment, the patient’s burns were
covered temporarily with allograft cadaver skin to protect her from
infection and minimize stress during the healing process. At the
Due to the extent of the patient’s burns, the Epicel grafts were
applied during three separate surgical procedures in August 2012.
In the first procedure, Epicel was grafted to the patient’s right arm
and right lower extremity. In the second procedure, it was grafted to
her left lower extremity, abdomen and face. In the third procedure,
the new skin was grafted to her back and buttocks. Each procedure
took about four hours to complete.
In this issue
About Epicel
2 Pediatric Burn Case Study
The use of Epicel® Cultured Epidermal Autografts (CEAs) is rare in
patients of any age. In fact, the procedure has only been performed
in about 1,500 patients during the last 25 years. Until this year,
it hadn’t been performed on a child at the Children’s Hospital of
Michigan since 2004.
4 Kidney Transplant Case Study
6 International Effort to Quantify and
Minimize Risks Associated with Pediatric
Catheterization Procedures
2
P E D I AT R I C E X P E R T S & I N N O V AT I O N S ®
But when split-thickness skin autografts are not a treatment option
due to the severity and extent of full-thickness burns, Children’s
Hospital of Michigan Burn Center specialists can use Epicel®
Cultured Epidermal Autografts (CEAs) – new skin grown in a
F A L L 2 0 12
Michigan’s Only Verified Pediatric Burn Center
The Burn Center at the Children’s Hospital of Michigan is the only pediatric burn center in Michigan – and one of only 10 in the nation – to
be verified by the American Burn Association (ABA) and the Committee on Trauma of the American College of Surgeons (ACS).
The designation as a verified pediatric burn center is granted based on the spectrum of quality care provided to pediatric burn patients
– from the pre-hospital phase through the rehabilitation process. No other burn center in the state is exclusively dedicated to the needs
of children and no other burn center has as much experience and specialized training with pediatric burn patients and their families.
Actual skin as attached to the gauze.
Skin is attached to sterile gauze and transferred in a
If you look on the left side you can see the actual skin.
sterile procedure in the OR to the patient.
According to Dr. Shanti, the patient is recovering well and is already
more than 80 percent healed. She remained an inpatient in the Burn
Center at the Children’s Hospital of Michigan through October
2012 to complete her physical and occupational therapy.
Close-up picture of the skin.
She now requires frequent outpatient follow-up care and continued
therapy as her new skin heals and matures, but she has an excellent
long-term prognosis. •
Christina Shanti, M.D., Director of the Burn Center
Education and training
Certifications
• Wayne State University School of Medicine, M.D., 1993–1997
• American Board of Surgery, 2004
• Wayne State University School of Medicine,
Residency in General Surgery, 1997–2003
• Critical Care Medicine, 2005
• Wayne State University School of Medicine,
Fellowship in Surgical Critical Care, 2000–2001
• Certificate of Special Competence in Pediatric Surgery, 2008
• Wayne State University School of Medicine,
Fellowship in Pediatric Surgery, 2003–2005
laboratory from a small sample of the patient’s own cells. The
Children’s Hospital of Michigan Burn Center is the state’s only
verified pediatric burn center exclusively dedicated to the needs
of children.
“If a patient has extensive third-degree burns on his or her body,
there simply isn’t enough healthy skin left to harvest and graft
over the burned areas,” said Heather Schaewe, R.N., M.S.N.,
C.P.N., Coordinator of the Pediatric Burn Program at the Children’s
Hospital of Michigan. “In cases like these, we need to look at
other options.”
W W W.CHIL DREN S D M C .ORG
• Pediatric Surgery, 2008
• Advanced Burn Life Support, 2009
Genzyme, one of the world’s leading biotechnology companies,
developed the biological process known as EPICEL® to grow
CEAs from the patient’s own cells using animal cells as a sort of
scaffolding. “This is live tissue grown in a plastic dish. It’s really a
remarkable technology,” said Christina Shanti, M.D., Director of
the Burn Center at the Children’s Hospital of Michigan.
But it’s a very challenging procedure. “The skin we get from the
lab is only four to eight cell layers thick,” said Dr. Shanti. “It is very
fragile and requires a long time to achieve the strength of nonburned skin. Because of its fragility, it is very difficult to engraft.”
P E D I AT R I C E X P E R T S & I N N O V AT I O N S
3
kidney transplant
CA S E S T U DY
The Health Journey of a Teen with ANCA
Glomerulonephritis: Before and After a
Deceased Donor Kidney Transplant
C A S E S T U DY
In October 2008, a 13-year-old girl from a small town in
Michigan’s Thumb area began to experience headaches, joint pain,
fatigue and fainting spells. Physicians at her local hospital diagnosed
her as having iron deficiency anemia. Her symptoms persisted
and she was also found to have mild renal dysfunction, which was
evaluated by an adult nephrologist in the area. A kidney biopsy
was performed, but the sample was inadequate for a diagnosis. Her
physicians quickly realized she would need significant pediatric
subspecialty care from a multidisciplinary team and transferred her
to the Children’s Hospital of Michigan.
When admitted to the Children’s Hospital of Michigan under the
pediatric nephrology team in December 2008, her labs indicated
severe anemia and significant kidney disease. A second kidney
biopsy and anti-neutrophilic cytoplasmic antibodies (ANCA) titers
confirmed the diagnosis of Microscopic Polyangiitis (MPA) – a
form of autoimmune vasculitis presenting with p-ANCA positive
crescentic glomerulonephritis. Her severe anemia was also a part of
the vasculitis-complex.
She was treated with high-dose steroid pulses and monthly
intravenous cyclophosphamide. She had aggressive disease and
did not respond to standard treatment. In January 2009, a central
line access was obtained and she received eight plasmapheresis
treatments. She also received four rituximab doses, which have been
shown to have promising results in this disease. However, she went
into end-stage renal disease and started on hemodialysis in February
2009. She traveled nearly two hours each way two to three times a
week for these hemodialysis treatments and experienced symptoms
including high blood pressure and abdominal pain. Eventually, the
nephrology team decided to switch to peritoneal dialysis, but she
then suffered three episodes of peritonitis. She was hospitalized at
the Children’s Hospital of Michigan seven different times between
February and June 2009.
In October 2009, the pediatric nephrology team and family
decided that a kidney transplant would offer her the best chance of
4
P E D I AT R I C E X P E R T S & I N N O V AT I O N S a healthy life. None of her family members were compatible kidney
donors, so they proceeded with pre-transplantation testing and
evaluation in hopes of securing a deceased donor kidney through
the United Network for Organ Sharing (UNOS). As part of her
pre-transplant evaluation, she was seen by pediatric cardiologists,
hematologists/oncologists, orthopedic surgeons, ophthalmologists
and gastroenterologists to make sure she didn’t have any other
conditions that might complicate the kidney transplant.
Finally, in July 2010, she was cleared for transplantation and listed
in the UNOS system. Just a few months later, in October 2010,
she received a healthy kidney from a deceased donor. She did have
an initial acute rejection episode but responded to thymoglobulin
treatment. In the months after transplantation, she developed
Epstein-Barr virus (EBV) infection, which has made managing her
immunosuppressive therapy challenging. The transplant team at
the hospital strives to fine tune her immunosuppressive medications
and achieve a delicate balance – keeping the EBV in check while
preventing organ rejection and recurrence of her vasculitis. Amrish
Jain, M.D., Associate Director of the Kidney Transplant Program
at the Children’s Hospital of Michigan, reports that she has not
been admitted to the hospital for nearly two years. For the family’s
convenience, Joanne Dupuis, R.N., the post-transplant coordinator
at the Children’s Hospital of Michigan, located a laboratory near
her home to perform the advanced blood tests she requires. When
specialized tests like viral PCR and ANCA titers are required that
cannot be processed in the Thumb area, the laboratory sends her
blood samples overnight to the Children’s Hospital of Michigan for
processing.
Today, the patient is a 17-year-old senior in high school and enjoying
a much better quality of life. She’s active in cheerleading and sports,
even though she requires frequent blood lab work and occasional
clinic visits to the Children’s Hospital of Michigan for follow-up
care. She has a passion for photography and a giving nature; several
of her best photos are mounted in the new dialysis unit at the
Children’s Hospital of Michigan Specialty Center-Detroit. •
F A L L 2 0 12
Delivering Excellence
in Pediatric Kidney and
Liver Transplants
Pediatric
Transplant Team
DMC Children’s Hospital of Michigan and the Henry Ford
Hospital have a long history of collaboration in serving children
and their families. The institutions have partnered in pediatric
medical education and pediatric heart transplants for several years.
Today, Henry Ford Medical Group transplant surgeons are working
side-by-side with Children’s pediatric medical specialists to perform
kidney transplants at the hospital.
Pediatric Transplant Surgeons
“We’ve had an excellent relationship with
the Henry Ford Hospital for many years
and we’re expanding our services to
include kidney and liver transplants.”
Eight exceptional transplant surgeons from the Henry Ford Medical
Group – all of whom have been trained in pediatric surgery – have
joined the medical staff of the Children’s Hospital of Michigan and
began seeing patients at the hospital in July.
“We’ve had an excellent relationship with the Henry Ford Hospital
for many years. We already share a Certificate of Need (CON) with
them for heart transplants,” said Richard A.K. Reynolds, M.D.,
MHCM, FRCSC, FACS, surgeon-in-chief and chief of pediatric
orthopaedic surgery at the Children’s Hospital of Michigan. “It’s
been a very successful relationship and what we’re doing now is
expanding it to include kidney and liver transplants.”
Tej K. Mattoo, M.D., D.C.H., F.R.C.P., F.A.A.P., serves as division
chief of Nephrology and Hypertension at the Children’s Hospital
of Michigan. With his division seeing more than 4,000 patients a
year – including 30 to 40 children on dialysis – he welcomes his
new surgical colleagues who have joined the transplant team, and
expects the volume of kidney transplants performed at the hospital
to increase in the coming year.
In addition, he said the new liver transplant program at the
Children’s Hospital of Michigan will help improve quality of care,
continuity of care and convenience for patients and their families.
“Instead of sending patients outside of the area for liver transplants,
we can manage their medical and surgical care right here,” he said. •
W W W.CHIL DREN S D M C .ORG
Top row, L to R: Dean Kim, M.D., Chief, Pediatric Transplant
Program at the Children’s Hospital of Michigan; Surgical Director,
Kidney and Pancreas Transplant program at the Henry Ford
Transplant Institute; Marwan Abouljoud, M.D., Director of the Henry
Ford Transplant Institute; David Bruno, M.D.; Jason Denny, M.D.
Bottom row, L to R: Marwan Kazimi, M.D.; Lauren Malinzak, M.D.;
Gabriel Schnickel, M.D.; Atsushi Yoshida, M.D.
Pediatric Nephrology Specialists
L to R: Tej K. Mattoo, M.D., D.C.H., F.R.C.P. (UK), F.A.A.P., Chief,
Pediatric Nephrology and Hypertension at the Children’s Hospital
of Michigan; Melissa Gregory, M.D. (not pictured); Amrish Jain,
M.D.; Gaurav Kapur, M.D.; Sweety A. Srivastava, M.D.
Pediatric Urology Specialist
Yegappan Lakshmanan, M.D., F.A.A.P.,
F.R.C.S.Ed., Chief, Pediatric Urology at the
Children’s Hospital of Michigan
Multidisciplinary Team
Denise Motowski, B.S., M.B.A., Transplant Program, Director;
Laura Roscoe, R.N., Pre-transplant Coordinator; Joanne Dupuis,
R.N., M.S.N., C.P.N., Post-transplant Coordinator;
Autumn Gallagher, L.M.S.W., Transplant Social Worker;
Jill Brackenbury, R.D., Dietitian; Kevin Biglin, Pharm.D.,
Pharmacist; Preeya Taormina, Ph.D., Clinical Psychologist;
Sharon Woods, Financial Coordinator
P E D I AT R I C E X P E R T S & I N N O V AT I O N S
5
Director of Cardiac Catheterization Lab Leads
International Effort to Quantify and Minimize Risks
Associated with Pediatric Catheterization Procedures
What are the precise complication rates associated with specific cardiac catheterization
procedures in children? Which pediatric patients are at a higher risk of complications?
The truth is: No one really knows for sure.
But a DMC Children’s Hospital of Michigan interventional cardiologist is working with pediatric cardiac catheterization
labs on three continents to develop a one-of-a-kind Risk Stratification Registry for pediatric cardiac catheterization
procedures – and the data they’re collecting promises to minimize risks and improve patient outcomes.
Thomas Forbes, M.D.,
co-director of the Cardiac
Catheterization Laboratory at the
Children’s Hospital of Michigan
and professor of medicine at the
Wayne State University School of
Thomas Forbes, M.D.
Medicine is co-founder of the
Congenital Cardiovascular Interventional Study Consortium
(CCISC), the first longitudinal study of its kind. As part of the
CCISC study, Dr. Forbes helped develop the world’s first and only
Risk Stratification Registry for pediatric cardiac catheterization
procedures. He now serves as one of the co-investigators on the
registry project, which is based at the Children’s Hospital of
Michigan, and is helping identify and refine risk stratification criteria
and analyze data to quantify risks and improve patient outcomes.
Currently, 18 pediatric catheterization labs in the United States,
South America and Europe are participating in the Risk Stratification
Registry. Additional catheterization labs are expected to join the
registry in the coming months. So far, more than 12,000 patient
procedures have been cataloged and analyzed as part of the registry.
“It’s our hope that we can use the registry data to better understand
the risks that children face during cardiac catheterization procedures
and we can find ways to improve quality and minimize patient
risks,” Dr. Forbes said.
Here’s how it works: At participating institutions, patients are given
a risk score ranging from 0 to 20 before undergoing any cardiac
catheterization procedure. The risk score is calculated based on a
variety of factors such as patient weight, age, diagnosis and medical
status. “Did the patient come from home for the procedure or was
he in the ICU? Was the patient on a ventilator and taking multiple
medications to keep his blood pressures up or did he walk in off the
6
P E D I AT R I C E X P E R T S & I N N O V AT I O N S street? All these factors play a role in understanding the patient’s
risk,” Dr. Forbes said.
The patient’s risk score is calculated and entered into the registry.
After the procedure, the risk score is compared against outcomes
and complications. Preliminary results of the study reveal that
patients with a risk score of 5 or less generally have less than a one
percent risk of complications. Patients with a risk score greater than
13 generally have a complication rate of approximately 10 percent.
Dr. Forbes is excited about the registry, not only because it provides
a way to quantify risks, but also because it holds the potential to improve
quality and minimize complications during catheterization procedures.
“We may find that at most institutions patients with a certain
risk factor or risk score usually have a complication rate of, say, six
percent. But let’s say patients with those same risk factors have a
significantly lower complication rate in Philadelphia,” Dr. Forbes
said. “What are they doing differently there? What can we learn
from them?”
The American Board of Pediatrics shares Dr. Forbes’ enthusiasm
for the Risk Stratification Registry. The board recently endorsed
the project by identifying participation in the registry as one of the
ways interventional cardiologists can earn Part IV Maintenance of
Certification (MOC) credits.
“We’re certainly very pleased to be recognized by the American
Board of Pediatrics in this way,” Dr. Forbes said. “It adds a bit of
credibility to our efforts.”
Preliminary results of the study will be published in a medical
journal later this year. After that, Dr. Forbes and his colleagues hope
to use what they’ve learned from the first 12,000 patient procedures
in the registry to improve outcomes and minimize risks for the next
20,000 patients. •
F A L L 2 0 12
Division Chiefs
Pediatrics
Pediatrician-in-Chief
Ashok Sarnaik, M.D.
Allergy/Immunology
Elizabeth Secord, M.D.
Cardiology
Richard Humes, M.D.
Critical Care Medicine
Kathleen Meert, M.D.
Dermatology
Darius Mehregan, M.D.
Education
Deepak Kamat, M.D.
Emergency Medicine/Toxicology
Prashant Mahajan, M.D.
Endocrinology
Chandra Edwin, M.D.
Gastroenterology
Mohammad El-Baba, M.D.
General Pediatrics/Adolescent Medicine
Genetic and Metabolic Disorders
Yvonne M. Friday, M.D.
David Stockton, M.D.
Hematology and Oncology (co-chiefs)
Infectious Diseases
Jeffrey Taub, M.D.
Madhvi Rajpurkar, M.D.
Basim I. Asmar, M.D.
Neonatology
Seetha Shankaran, M.D.
Nephrology
Tej K. Mattoo, M.D.
Neurology
Harry T. Chugani, M.D.
Pediatric Hospital Medicine
Allison Ball, M.D.
Pediatric Prevention Research Center
Pharmacology
Diane Chugani, Ph.D.
Physical Medicine and Rehabilitation
Editors and
Contributors
Xiaoming Li, M.D.
Edward R. Dabrowski, M.D.
Pulmonary Medicine
Ibrahim F. Abdulhamid, M.D.
Rheumatology
Matthew Adams, M.D.
Surgery
Surgeon-in-Chief
Richard Reynolds, M.D.
Anesthesiology
Maria M. Zestos, M.D.
Cardiovascular Surgery
Henry L. Walters, III, M.D.
Developmental Dentistry and Orthodontics
James P. Stenger, D.D.S.
General Surgery
Joseph Lelli, M.D.
Neurosurgery
Steven D. Ham, D.O.
Ophthalmology
John D. Roarty, M.D.
Oral and Maxillofacial Surgery
Joseph M. Hildebrand, D.D.S.
Orthopaedic Surgery
Richard Reynolds, M.D.
Otolaryngology
Michael Haupert, D.O.
Plastic and Reconstructive Surgery
Urology
Arlene A. Rozzelle, M.D.
Yegappan Lakshmanan, M.D.
Other medical services
Imaging
Thomas L. Slovis, M.D.
Pathology and Laboratory Medicine
Psychiatry and Psychology
Janet Poulik, M.D.
David Rosenberg, M.D.
Experts & Innovations is a publication produced by the Marketing Department of Children’s Hospital of Michigan.
Anika Corbett, M.A.
Director, Marketing
Editor
Herman B. Gray, M.D., M.B.A.
President
Lori Mouton
Vice President,
Marketing
Thomas Frey, APR
Feature Writer
Shoreline Graphics, Inc.
Design and Printing
The physicians in this publication are members of the medical staff at the DMC Children’s Hospital of Michigan, but some are independent contractors who are neither employees nor agents of the
Children’s Hospital of Michigan; and, as a result, the DMC Children’s Hospital of Michigan is not responsible for the actions of any of these physicians in their medical practices.
Physician Link Line:
Your Connection to Pediatric Subspecialists
Want to admit a patient to DMC Children’s
Hospital of Michigan? Consult with a pediatric
subspecialist? Schedule an appointment? Check
the status of your patient? Just call the Physician
Link Line at 1 (877) 99-4THEM (8436).
Available 24 hours a day, Physician Link Line is the fastest
and most convenient way for referring physicians to
contact the Children’s Hospital of Michigan.
W W W.CHIL DREN S D M C .ORG
• Any physician or physician office can call
1 (877) 99-4THEM (8436).
• A specially trained Physician Link Line representative
will find out exactly what is needed and connect you
to the appropriate physician or department.
• If the appropriate physician or department is not
immediately available, the Physician Link Line
representative will take your number and call you back
when a connection is made.
• Once connected, the Physician Link Line representative
will stay on the line to facilitate any additional
connections and requests that might be needed.
P E D I AT R I C E X P E R T S & I N N O V AT I O N S
7
3901 Beaubien
Detroit, MI 48201
Fall 2012
Pediatric Burn Treatment
The Burn Center at the Children’s Hospital of Michigan is the only pediatric burn center in the state verified
by the American Burn Association (ABA) and the Committee on Trauma of the American College of Surgeons
(ACS). It provides innovative treatments for children with severe burns over large portions of their bodies –
like Epicel® skin grafts grown in a laboratory from the patient’s own skin cells – but the Burn Center at the
Children’s Hospital of Michigan is not just for children with large burns. Physicians should refer children
directly to the Burn Center for:
• Burns that involve the face, hands, feet, genitalia,
perineum, or major joints
• Third-degree burns of any size
• Electrical burns, including lightning injury
• Chemical burns
• Friction burns
• Inhalation injury
• Burn injury in patients with pre-existing medical
disorders that could complicate management, prolong
recovery, or affect mortality
• Burn injury in patients who will require special social,
emotional and/or long-term rehabilitative intervention
The Burn Center at the Children’s Hospital of Michigan treats hundreds of children annually – making it one
of the highest volume pediatric burn centers in the nation.
Look inside and learn more!
To consult with a pediatric specialist at the Children’s Hospital of Michigan,
call 1 (877) 99-4THEM (8436).