PICAN

By: Dr. David J. Askenazi _ medical director of the Pediatric and Infant Center for Acute Nephrology (PICAN) at Children’s of Alabama and Associate Professor of Pediatrics at the University of Alabama at Birmingham (UAB). The PICAN Center works to improve the health and care of infants and children who are at risk for acute kidney disease.


Hospitalized children are at great risk to develop abrupt loss of kidney function. The risk factors for acute kidney injury include toxic side effects from drugs administered to treat a critical illnesses, shock from sepsis, decreased blood flow around the time of surgery and congenital conditions. Reducing those risks, and supporting the failed kidney during this time is the job of the Pediatric and Infant Center for Acute Nephrology (PICAN Center) established a year ago at Children’s of Alabama.

We take a three-pronged approach:

• Clinical services, which strive to provide the best of care
• Educational outreach here and throughout the country, which trains physicians and nurses to diagnose and support those with acute kidney damage
• Research, which leads to a better understanding of the diagnosis, risk factors and outcomes and develops new strategies for prevention and treatment

This all requires coordination and cooperation not only within Children’s but throughout other pediatric care centers at home and abroad.


We are now leading the Neonatal Kidney Collaborative, an international group of more than 20 centers that are interested in the topic of neonatal kidney problems. This collaborative has emerged from observations and studies showing that babies in neonatal intensive care units frequently develop acute kidney injury. It’s not surprising. Normally, babies develop a full complement of nephrons—functional units that make up our kidneys—during the first eight months in the womb. After that, we no longer produce nephrons. However, when born prematurely, nephron production cycle is cut short and babies can end up with fewer nephrons than normal. That can make them more susceptible to short and longterm problems including chronic kidney disease and high blood pressure. By collaborating with other centers, we can look at much broader demographics and much larger numbers of patients, which will allow us to make stronger inferences. Our first study launches in March and will be titled AWAKEN (Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates. This study will improve our ability to diagnose acute kidney injury, understand risk factors, and determine how fluid provision affects kidney and other outcomes.


Meanwhile, Children’s has joined eight other hospitals nationwide to implement a program called NINJA (Nephrotoxic Injury Negated by Just-in-Time Action). This quality improvement project screens every patient admitted to the hospital for medications known to have toxic side effects to the kidney. Historically there has been a tendency to accept this damage as necessary, but we are showing that with risk assessment and daily evaluation of the medications we give our patients, we can reduce the incidence and severity of acute kidney injury. The pharmacy “NINJA’s” look through the hospital census daily and find those who with high risk of toxicity, then they work with care teams to minimize use of these medications, monitor levels of kidney function and to ask the question: “Is it in the best interest of this patient to be on this medicine?” By paying close attention to these risks, we can make a difference in the occurrence or severity of an acute kidney injury.


There are many other initiatives involving our center but one in particular is worth mentioning. It involves a dialysis machine that we are employing for babies. In the past we have relied upon adult dialysis machines for dialyzing babies with kidney failure. Because these machines are not designed for babies, they carry added risk of bleeding and low blood pressure. So we found an opportunity to work with an FDA-approved machine called the Aquadex FlexFlow. It was designed to remove fluids from patients with heart failure but it also happens to be the right size to use on babies. We’ve adapted the machine in the intensive care units of Children’s of Alabama to clean a baby’s blood, remove extra fluid and balance electrolytes. We have been able to do this while avoiding the risks inherent to adult-sized dialysis machine.



Please visit our website at www.childrensal.org/pican or contact us with any questions at 205-638-9781

Be Aware of Unexpected Costs with Apple Products and Your EHR System

By Curtis Woods, COO of Integrated Solutions, a division of IT4thePlanet

While many of us are "wowed" by the cool factor and ease of use of Apple Products (the iPad, iPhone and MacBook's just to name a few), if you are in a clinical environment utilizing electronic Practice Management and/or Electronic Health Records applications - beware. Unless your EHR application has documented, built-in support for Mac products you may be disappointed with the cost of implementing these devices within the clinic.

Even if your EHR vendor fully supports Apple products, the clinic must have wireless technology in place to connect to the EHR application, whether it is located within your clinic or in the cloud. The wireless devices must be robust, deliver a strong signal to the device and ensure that the signal remains stable at all times. If any of these criteria are not in place, the user will experience dropped connections to the application, slow access to the application or both. It can get very frustrating quickly. The cost of the higher end wireless devices (named access points) that meet this criteria can be upwards of $900 each and in many instances more than one device will be required.

The cost of remote access applications also has to be considered. If your EHR provider does not inherently support an iPad or MacBook, remote access must be in place so that the device can connect to a system that is supported. The most widely used are Microsoft remote desktop services and Citrix. These applications provide a "virtual" desktop from the Apple device to a system where the EHR application is installed. The user connects to it from their device and then accesses the EHR application. The cost and impact of remote access within a clinic can be enormous and the requirements must be carefully researched in order to determine the complexity needed.

Eosinophilic Esophagitis Diagnosis on the Rise

By: Rajat N. Parikh, MD, Birmingham Gastroenterology Associates


Eosinophilic esophagitis (EoE) has been more and more frequently diagnosed in young adults at Birmingham Gastroenterology Associates in recent years. EoE is defined as a chronic immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. EoE was a diagnosis discovered in the early 1990's initially on patients that did not respond to standard anti-secretory therapy for GERD. The prevalence in the United States is estimated to be 55 per 100,000. The recent incidence rates of EoE in children exceed those of Inflammatory Bowel Disease.


Clinical manifestations in adults include dysphagia, food impaction, central chest pain, GERD-like symptoms/refractory heartburn, and upper abdominal pain. Younger children most commonly present with abdominal pain and difficulty feeding. There is a strong association of EoE with allergic conditions such as asthma, food allergies, environmental allergies, and atopic dermatitis. Multiple studies also note an association with celiac disease.


Diagnosis is made based on symptoms, endoscopy findings and histology of esophageal biopsies. Characteristically more than 15 eosinophils are seen per high power field on histology of esophageal biopsies. This finding should persist after at least two months of daily PPI therapy. Endoscopic appearance is classically a feline esophagus or ringed esophagus; however, endoscopy can be relatively normal appearing with mild narrowing or linear furrows and small whitish micro-abscesses. The disease can be patchy so biopsies are taken from the lower, mid, and upper esophagus. Imaging and labs do not play a major role in diagnosis.


Typical treatment for EoE include: elimination and elemental diets to decrease allergen exposure, acid suppression for reflux symptoms, topical glucocorticoids, and esophageal dilation for strictures. Other therapies being studied include systemic steroids, antihistamines, immunosuppressants and immunomodulators. Empiric elimination diets are quite effective but difficult to adhere to. Generally, the diet eliminates the most common foods that cause hypersensitivity in the U.S. including milk, egg, soy, wheat, peanuts/tree nuts, and fish/shellfish. This is also known as the six-food elimination diet (SFED). A patient with EoE will eliminate all of these food groups simultaneously and then reintroduce one at a time over a planned period to see which food group causes symptoms and should therefore be avoided. While effective, most patients have difficulty being compliant with elimination diets. Therefore, we commonly have assistance from allergists creating a testing-directed elimination diet based on skin prick testing (SPT) or atopy patch testing (APT).


Pharmacological therapy in addition to acid suppression and esophageal dilation where indicated revolves around use of topical steroids to coat the esophagus and decrease inflammation without causing significant systemic side effects. Options for adults include fluticasone by metered dose inhaler sprayed into the patient's mouth and then swallowed, not inhaled. Typical adult dosing is 220 mcg x 2 sprays twice daily. Lower dosing is used in younger children. Patients who do not respond to fluticasone are normally switched to a oral viscous budesonide which is normally prescribed at a compounding pharmacy. Adult dosing is normally 2 mg daily and lower dosing for children. This is normally made by mixing pulmicort respules with sucralose.


EoE is being diagnosed more commonly and incidence is on the rise. Current therapy is quite effective with more research into newer therapies is on the horizon. The American Partnership for Eosinophilic Disorders (www.apfed.org) is an advocacy group for patients with eosinophilic gastrointestinal disorders. Birmingham Gastroenterology Associates (www.bgapc.com) has been treating EoE for years and continually pursues the newest and best evidence-based therapies available.

What’s Up with the Balloon?

By: Brad Woodworth, MD, FACS & Michael J. Sillers, MD, FACS

(Dr. Woodworth)

(Dr. Sillers)



Undoubtedly you have heard much of the discussion about balloon sinuplasty (BSP). What is it and where does it fit into the spectrum of treating patients with sinusitis, in particular those who fail medical therapy and are candidates for surgical intervention? Simply stated, since its introduction in 2005, the balloon is one tool among many that can be used to open a blocked sinus. By using balloon catheter dilation technology to perform BSP, the outflow tracts of the maxillary, frontal and sphenoid sinuses can be dilated. No tissue is removed during BSP and the ethmoid sinus is not directly treated. Studies have shown that it can safely and effectively open a sinus outflow tract and it will stay open, so the effect is durable. Additional studies have shown that this technology can be used safely in the office setting under local anesthesia in appropriately selected patients.


 So who is a candidate for BSP? What needs to be stated is that the indications for sinus surgery have not changed simply because there is a new tool in our tool kit. The overwhelming majority of patients with sinus disease improve with medical therapy. For those patients with chronic rhinosinusitis (defined by 12 weeks of continuous symptoms with endoscopic and/or CT evidence of disease) who do not respond to maximal medical therapy, there is good evidence that they benefit from traditional functional endoscopic sinus surgery (FESS). In a recent prospective study comparing BSP to FESS, BSP was shown not to be inferior to FESS in patients with limited disease who underwent maxillary sinus intervention only without concomitant septal and/or turbinate surgery. While this is encouraging for our patients with limited disease this subgroup represents a very small percentage of all CRS patients. The broad application of this data to patients with advanced disease is controversial at best. Traditional FESS remains the method of choice and has been shown for over 25 years to be safe, effective, and is performed with minimal morbidity. More controversial is the use of BSP in patients with a history of recurrent sinus infections (recurrent acute rhinosinusitis) but demonstrate no radiographic evidence of sinus inflammation, perhaps only radiographic anatomic variations. The consensus opinion of thought leaders in rhinology is that operating on sinuses without evidence of inflammation is not indicated, regardless of the method or tool used. The surgical management of a deviated nasal septum (septoplasty) and enlarged inferior and middle turbinates (turbinoplasty) without sinus surgery is often effective at relieving symptoms mimicking sinus disease and does not subject the patient to the additional risks and associated costs of unnecessary sinus surgery.


In an era of cost containment one important topic to address regarding BSP is the addition of disposable devices. This technology is not inexpensive and tends to add approximately $1000/case. This additional cost may be partially offset by the potential reduction in post-operative care. However, currently in Alabama, Blue Cross Blue Shield does not consider BSP a covered benefit in the operating room or the office setting and does not reimburse when the appropriate CPT codes for balloon sinus dilation are utilized.


Balloon sinuplasty is exciting technology and represents an advance in our efforts to pursue less invasive methods for treating patients with refractory sinus disease. Its use is indicated in patients with demonstrable inflammatory disease of the maxillary, sphenoid, and frontal sinuses. Traditional functional endoscopic sinus surgery is still the method of choice in treating patients with advanced disease.


Brad Woodworth, MD, FACS James J. Hicks Associate Professor of Surgery Otolaryngology-head and Neck Surgery, UAB

Michael J. Sillers, MD, FACS Clinical Professor of Surgery Otolaryngology-Head and Neck Surgery, UAB Alabama Nasal and Sinus Center