R E P O R T A N N U A L S U R G E R Y O F 2011 2012 T E X A S C H I L D R E N ’ S H O S P I TA L D E PA R T M E N T O F S U R G E R Y A N N U A L R E P O R T 2 0 11 - 2 0 12 D E P A R T M E N T B Thank you for your interest in the Department of Surgery Annual Report. This year’s publication highlights our leading surgical program, provides updated data for each division and showcases the treatments, innovations and expertise taking place at Texas Children’s Hospital. The Department of Surgery is on track to complete approximately 25,000 operating room cases and more than 100,000 outpatient visits in 2012. In addition, we became the first hospital in the southwestern United States to perform an in utero procedure to treat congenital diaphragmatic hernia. We established a comprehensive Sports Medicine Program to treat patients with all types of sports-related injuries and disorders. We were the lead site for a groundbreaking trial of the Berlin Heart EXCOR® Pediatric Ventricular Assist Device, the only pediatric mechanical circulatory support device designed specifically for infants and small children that received approval from the United States Food and Drug Administration, and so much more. Our surgical capabilities continued to expand with the opening of surgical suites at Texas Children’s Hospital West Campus, the first pediatric community hospital in Houston, and Texas Children’s Pavilion for Women, a comprehensive obstetrics and gynecological care facility that provides some of the most advanced technologies and treatments available for women, mothers and babies. Texas Children’s Hospital was recently ranked #4 among top children’s hospitals in the nation and was also ranked in all ten subspecialties in the 2012 U.S.News & World Report’s list of America’s Best Children’s Hospitals. While we are pleased our hospital ranks among the best in the nation, we consistently strive to improve our patient outcomes, satisfaction levels and medical advancements. This report is part of our ongoing effort to examine our programs, be transparent with our activities and to improve the quality of care we provide to our patients. I hope you find it valuable and informative. Sincerely, Mark A. Wallace President and Chief Executive Officer, Texas Children’s Hospital 1 D E P A R T M E N T O F S U R G E R Y A N N U A L R E P O R T 2 011-2 012 Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Texas Children’s Hospital and Baylor College of Medicine . . . . . . . . . . . . . . . . . . . . . 3 Department of Surgery . . . . . . . . . . . . . . . . . . . . . . 5 Berlin Heart EXCOR Pediatric. . . . . . . . . . . . . . . . . . 13 ® Department of Surgery Research Seed Grants. . . . . 16 Department of Anesthesiology . . . . . . . . . . . . . . 19 Surgical Divisions Congenital Heart Surgery . . . . . . . . . . . . . . . . . . . . . . . 25 Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Orthopaedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Otolaryngology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Pediatric and Adolescent Gynecology. . . . . . . . . . . . . 55 Pediatric General Surgery . . . . . . . . . . . . . . . . . . . . . . . 63 Plastic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Transplant Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Department of Surgery Services Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Operating Room and Perioperative Services . . . . . . . 90 Trauma Services and the Center for Childhood Injury Prevention. . . . . . . . 92 Medical Staff Directory . . . . . . . . . . . . . . . . . . . . . . . . . 98 2 Dear colleagues, parents and friends, I am pleased to share with you the second edition of the Department of Surgery Annual Report from Texas Children’s Hospital. The Department of Surgery had a busy and productive year pursuing our vision to set the standard for quality in pediatric surgical care, educate tomorrow’s surgical leaders and conduct pioneering research. We have launched several new initiatives to meet the needs of children in the community, including the area’s first pediatric Sports Medicine Program, a dedicated Voice and Swallowing Clinic, comprehensive aerodigestive care, and a continued focus on craniofacial anomalies and transplant services. Additionally, as Texas Children’s Hospital West Campus has grown, we have continued to grow our presence to meet the needs of the west Houston community during the day and after hours. The opening of Texas Children’s Pavilion for Women has enabled us to expand our fetal surgical capabilities and treatment of neonates needing surgical care as well as allowed us to continue to grow into supporting select adult surgical needs. Moreover, our focus on patient outcomes led us to establish the Surgical Outcomes Center. This center enables us to track, analyze and report the outcomes of procedures and identify areas for improvement and research within Texas Children’s Hospital. As part of our ongoing commitment to provide the very best possible surgical care, we have added several new faculty to our already outstanding team. We plan to continue to add faculty during the next year in order to further expand our programs to meet the needs of our patients and their families. I hope you enjoy reading about our outstanding surgical team here at Texas Children’s Hospital. I am privileged to work with these dedicated surgeons. With deepest respect, I remain, Sincerely yours, Charles D. Fraser, Jr., M.D. Surgeon-in-Chief, Texas Children’s Hospital Donovan Chair and Chief of Congenital Heart Surgery, Texas Children’s Hospital Susan V. Clayton Chair in Surgery, Baylor College of Medicine Professor of Surgery and Pediatrics, Baylor College of Medicine 3 Texas Children’s Hospital and Baylor College of Medicine Texas Children’s Hospital, located in the Texas Medical Center, is committed to a community of healthy children by providing the finest pediatric patient care, education and research. Renowned worldwide for its expertise and breakthrough developments in clinical care and research, Texas Children’s Hospital is nationally ranked in all of the ten subspecialties in U.S.News & World Report’s list of America’s Best Children’s Hospitals and was one of only twelve hospitals in the nation to make its Honor Roll in 2012. Texas Children’s also operates Texas Children’s Pediatrics, the nation’s largest primary pediatric care network, with more than 45 offices throughout the greater Houston community and Texas Children’s Health Plan, the nation’s first health maintenance organization (HMO) created just for children. Texas Children’s Hospital is affiliated with Baylor College of Medicine (BCM), ranked by U.S.News & World Report as one of the nation’s top 25 medical schools for research. Texas Children’s Hospital serves as BCM’s primary pediatric training site, and BCM faculty are the division chiefs and staff physicians of Texas Children’s patient care centers. The collaboration between Texas Children’s Hospital and BCM is one of the top 10 such partnerships for pediatric research funding from the National Institutes of Health. The hospital’s medical staff includes more than 1,500 board-certified, primary-care physicians, pediatric subspecialists, pediatric surgical subspecialists and dentists, offering the highest level of pediatric care in more than 40 subspecialties, programs and services and a support staff in excess of 8,500. 4 Mission D epartment of S ur g er y M i ss i on S tatement The Department of Surgery at Texas Children’s Hospital strives to provide the highest quality surgical care in a collaborative and family-centered environment while being the national leader in surgical education and research. Vision D epartment of S ur g er y V i s i on S tatement The surgeons of Texas Children’s Hospital are committed to setting the standard for quality surgical care, to inspiring and educating the next generation of surgeons, and to being leaders in research that changes lives. DEPARTMENT OF SURGERY Department of Surgery The Department of Surgery at Texas Children’s Hospital represents a dedicated team of pediatric-focused surgeons from nine surgical divisions – Congenital Heart, Dental, Neurosurgery, Ophthalmology, Orthopaedics, Otolaryngology, Pediatric General Surgery, Plastic Surgery and Urology. In conjunction with our partners in Pediatric and Adolescent Gynecology and Transplant Services, we have over 60 full time surgeons and more than 500 Texas Children’s Hospital and Baylor College of Medicine employees focused on ensuring children get the care they need. With an annual operating revenue budget in excess of $300 million, our team’s tireless efforts are demonstrated in the approximately 25,000 operating room cases and 100,000 outpatient visits completed in 2012. Significant external research support and activity are highlighted by millions of dollars in external research funding and numerous articles and presentations given nationally and internationally each year. Our team is dedicated to caring for children in and around the greater Houston area through our four community health centers and two Texas Children’s Hospital locations. Additionally, we take great pride in caring for children at other hospitals in the Houston area and from all 50 states and over 70 countries around the globe. When parents want the very best for their child, we are humbled that they make Texas Children’s Hospital their choice. It is an honor to care for these children and a responsibility we do not take lightly. 5 6 DEPARTMENT OF SURGERY 2012 * D epartment of S ur g er y O verv i ew S U RG IC AL DIVI S ION 2 012 * CLINIC VISITS 2 012 * O P E R AT I N G R O O M CASES Congenital Heart Surgery 1,421 771 Dental 2,354 804 Neurosurgery 5,388 969 Ophthalmology 16,158 1,283 Orthopaedics 21,883 2,182 Otolaryngology 19,715 9,838 Pediatric and Adolescent Gynecology 5,509 237 11,300 5,567 Plastic Surgery 4,152 1,080 Transplant Services 2,950 96 Urology 11,213 2,093 102,043 24,920 Pediatric General Surgery TOTAL * P ro j ected Operating room cases are defined as cases when operating room staff and supplies are used. Cases with multiple procedures count as one case and are attributed to the service line of the primary surgeon. Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital locations. Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. DEPARTMENT OF SURGERY Texas Children’s Hospital West Campus Texas Children’s Hospital West Campus is Houston’s first community hospital designed, built and staffed exclusively to care for children. Outpatient services opened in December 2010, and inpatient services and the Emergency Center opened in April 2011. This state-of-the-art 514,000-square-foot facility incorporates best practices in pediatric treatment and serves the community as the premier resource center for child wellness and healing. Within an ambulatory surgery center model, the following Department of Surgery divisions provide outpatient clinic and/or surgical coverage at Texas Children’s Hospital West Campus: • Orthopaedics (added onsite after hours care in 2011) • Ophthalmology • Otolaryngology • Pediatric General Surgery (added onsite after hours care in 2011) • Pediatric and Adolescent Gynecology • Plastic Surgery (added in 2012) • Urology 7 8 DEPARTMENT OF SURGERY Over the past year, we established a multispecialty Sports Medicine Program. This program provides comprehensive and convenient diagnosis, evaluation and treatment for all types of pediatric and young adult athletic-related injuries and conditions. A $10 million capital expansion is planned in 2013 to allow the program to be based at Texas Children’s Hospital West Campus. Additionally, a top strategic focus this year was to expand emergency and operating room coverage for anesthesiology, orthopaedics and pediatric general surgery. The purpose of this initiative was to better serve the community and add capacity to the system. Perioperative services are now available seven days a week, including after hours. Moving forward, Texas Children’s Hospital West Campus will continue to expand existing surgical capabilities, particularly within orthopaedics, pediatric general surgery, plastic surgery and otolaryngology, as well as the Emergency Center. In addition, we will augment our services with coverage by more surgical divisions and increase the number of available operating rooms. The facility is moving toward a higher level of care that will enable more complex, inpatient surgeries in the future. 2012 * O perat i n g R oom C ases C ompleted at T e x as C h i ldren ’ s Hosp i tal W est C ampus* 1,814 Otolaryngology 771 Pediatric General Surgery 363 356 Urology Orthopaedics Ophthalmology Plastic Surgery 65 12 * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital West Campus. DEPARTMENT OF SURGERY Texas Children’s Pavilion for Women Fully opened in March 2012, Texas Children’s Pavilion for Women enhances the Department of Surgery’s capabilities to care for women, mothers and babies. As a leader in the fields of obstetrics, gynecology, fetal and pediatric medicine, the Pavilion for Women offers the most advanced technologies and treatments available from before conception to after delivery. A long list of amenities and technology, including an expanded neonatal intensive care unit, augment current newborn surgical capacity. The Fetal Surgery Program benefited dramatically from new operating rooms accommodating in utero surgical procedures including spina bifida repair, twin-twin transfusion syndrome laser therapy, interventional cardiology and balloon tracheal occlusion for severe congenital diaphragmatic hernia. If surgery such as an EXIT procedure is needed, the baby can be transported quickly to the main hospital via the pedestrian sky bridge, also known as the Miracle Bridge. SEPT AUG JUL 394 OCT 378 404 405 329 2012 JUN 326 MAY 286 APR 282 MAR 242 FEB JAN 268 P A T I E N T B I R T H S A T T E X A S C HI L D R E N ’ S P A V I L I O N F O R W O M E N in 2012 9 10 DEPARTMENT OF SURGERY With the Pavilion for Women, Texas Children’s has opened the door to expanded adult surgical capabilities. An extremely active caseload of obstetric and gynecologic procedures is being performed and will continue to grow. William Fisher, M.D., Director of Baylor College of Medicine’s Elkins Pancreas Center and a renowned pancreatic surgeon, is the Department of Surgery’s link to the Pavilion for Women as the Medical Director of Adult Surgery at Texas Children’s Hospital. Dr. Fisher oversees the non-obstetrics and gynecology growth of surgery at the Pavilion for Women. 2012 * O perat i n g R oom C ases C ompleted at T e x as C h i ldren ’ s P av i l i on for W omen * 771 Fetal 11 Pediatric General Surgery Urology 114 3 * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Pavilion for Women. DEPARTMENT OF SURGERY Surgical Outcomes Center This year, the Departments of Surgery and Quality at Texas Children’s Hospital teamed up to establish an innovative Surgical Outcomes Center that will track, analyze and report the outcomes of procedures within Texas Children’s Hospital. The Surgical Outcomes Center provides a central resource and infrastructure to examine surgical outcomes data in order to identify where performance can be improved and valuable research can occur. The Surgical Outcomes Center is working closely with physicians to: • Collect data on procedures, complications and outcomes • Analyze trends in data • Assimilate outcomes information to improve beside care through protocol establishment and review • Establish hospital and national benchmarks • Optimize financial models • Ensure accurate reporting to external stakeholders • Report long-term functional outcomes Moreover, the Surgical Outcomes Center will enable surgical faculty to answer key questions patients, families and legal guardians have about medical conditions. For example, the number of procedures that have been done at Texas Children’s Hospital, typical results and if those results are improving over time, estimated cost of the operation, what long-term quality of life and functional outcomes to expect and more. The Surgical Outcomes Center’s team of research nurses, computer programmers, data architects and specialists, outcomes analysts and research statisticians will work closely with Department of Surgery physicians to reach these goals. 11 12 DEPARTMENT OF SURGERY Surgical Quality Programs The Department of Surgery is integral to the overall quality and safety mission of Texas Children’s Hospital. Quality and outcomes management uses a specific methodology to optimize safety, efficacy and efficiency of care delivery. Current institutional quality goals include decreasing specific hospital-acquired conditions, serious safety events and preventable re-admissions. Additionally, the Department of Surgery, through the newly developed Surgical Outcomes Center, tracks clinical outcomes and also provides process and outcomes data to several national collaboratives. In the past year, the Surgical Quality Team, led by Thomas Luerssen, M.D., F.A.C.S., F.A.A.P., Chief Quality Officer Surgery and Chief of Neurosurgery at Texas Children’s Hospital, has completed projects focused on the surgical safety checklist, obtaining current and accurate operative reports, tracking a series of “triggers” that impacts the outcome of surgical patients or procedures, and prevention of serious safety events. A project aimed at reducing acute postoperative pain in the three days following surgery resulted in a decrease of moderate or severe pain by almost 50%. American College of Surgeons, National Surgical Quality Improvement Program (NSQIP)1 Texas Children’s Hospital began participating in the Pediatric NSQIP program in 2011. Pediatric NSQIP currently has 47 participating pediatric sites and is the first multispecialty outcomes-based program to measure the quality of children’s surgical care. David E. Wesson, M.D., Associate Surgeon-in-Chief, Chief of the Department of Surgery and Medical Director of Trauma Services at Texas Children’s Hospital is Texas Children’s surgeon champion for the program. NSQIP collects prospective data on more than 130 data points on all patients over 18 years of age undergoing major operations who meet program criteria. Data is collected by a highly trained surgical clinical reviewer. After the data is analyzed and risk-adjusted, an annual report is provided to each site that benchmarks its outcomes against other participating sites. Because of our recent partnership with NSQIP, statistically significant information is not available to share at this time. We look forward to including this data in subsequent versions of our annual report. 1 DEPARTMENT OF SURGERY Berlin Heart EXCOR® Pediatric Recently, the United States Food and Drug Administration (FDA) granted humanitarian device exemption for the Berlin Heart EXCOR® Pediatric Ventricular Assist Device – the only pediatric mechanical circulatory support device designed specifically for infants and small children. This was a landmark day for physicians who treat children dying of heart failure whose only hope is a heart transplant. Small children awaiting heart transplantation face a long time on the waiting list due to limited availability of donor organs and a mortality rate while waiting of approximately 25 percent due to progressive organ system failure. Before this FDA ruling, physicians longed for a reliable circulatory support device so children could survive until an appropriate donor heart became available. The journey for the FDA’s approval began with a multi-year, multi-institution study led by Texas Children’s Hospital. Starting in 2005, a trans-Atlantic dialogue was initiated between the Berlin Heart Corporation, clinicians in North America and the FDA to design and conduct the first ever prospective pediatric ventricular assist trial in the world. The study design addressed questions of safety and benefit of the Berlin Heart in supporting children with heart failure until they received a heart transplant. This extremely ambitious study involved detailed analysis and ongoing multicenter data collection coordination in critically ill children with rapidly progressive heart disease. During the course of the study, Texas Children’s implanted 27 Berlin Hearts – more than any other center in the U.S. – and our results were very encouraging. This groundbreaking trial has become part of the rich legacy of surgical advancements that have happened at Texas Children’s Hospital. Findings from this unprecedented study were published in the New England Journal of Medicine in August 2012.2 Outcomes for 48 children (infants – 16 years) who received the Berlin Heart from 2007 – 2010 were compared to patients supported by extracorporeal membrane oxygenation (ECMO). The n e w e ng l a n d j o u r na l of m e dic i n e original article Prospective Trial of a Pediatric Ventricular Assist Device Charles D. Fraser, Jr., M.D., Robert D.B. Jaquiss, M.D., David N. Rosenthal, M.D., Tilman Humpl, M.D., Ph.D., Charles E. Canter, M.D., Eugene H. Blackstone, M.D., David C. Naftel, Ph.D., Rebecca N. Ichord, M.D., Lisa Bomgaars, M.D., James S. Tweddell, M.D., M. Patricia Massicotte, M.D., Mark W. Turrentine, M.D., Gordon A. Cohen, M.D., Ph.D., Eric J. Devaney, M.D., F. Bennett Pearce, M.D., Kathleen E. Carberry, R.N., M.P.H., Robert Kroslowitz, B.S., and Christopher S. Almond, M.D., M.P.H., for the Berlin Heart Study Investigators From Texas Children’s Hospital (C.D.F., L.B., K.E.C.) and Baylor College of Medicine (C.D.F., L.B.), Houston, and Berlin Heart, The Woodlands (R.K.) — all in Texas; Duke Children’s Hospital and Health Center, Duke University School of Medicine, Durham, NC (R.D.B.J.); Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, CA (D.N.R.); the Hospital for Sick Children, University of Toronto, Toronto (T.H.), and Stollery Children’s Hospital, University of Alberta School of Medicine, Edmonton (M.P.M.) — both in Canada; St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis (C.E.C.); Heart and Vascular Institute and Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (E.H.B.); University of Alabama School of Medicine, Birmingham (D.C.N., F.B.P.); Children’s Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee (J.S.T.); Riley Hospital for Children, Indiana University School of Medicine, Indianapolis (M.W.T.); Seattle Children’s Hospital, University of Washington School of Medicine, Seattle (G.A.C.); C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor (E.J.D.); and Children’s Hospital of Boston, Harvard Medical School, Boston (C.S.A.). Address reprint requests to Dr. Fraser at Texas Children’s Hospital, Baylor College of Medicine, 6621 Fannin St., WT 19345H, Houston, TX 77030, or at [email protected] A BS T R AC T BACKGROUND Options for mechanical circulatory support as a bridge to heart transplantation in children with severe heart failure are limited. METHODS We conducted a prospective, single-group trial of a ventricular assist device designed specifically for children as a bridge to heart transplantation. Patients 16 years of age or younger were divided into two cohorts according to body-surface area (cohort 1, <0.7 m2; cohort 2, 0.7 to <1.5 m2), with 24 patients in each group. Survival in the two cohorts receiving mechanical support (with data censored at the time of transplantation or weaning from the device owing to recovery) was compared with survival in two propensity-score–matched historical control groups (one for each cohort) undergoing extracorporeal membrane oxygenation (ECMO). RESULTS For participants in cohort 1, the median survival time had not been reached at 174 days, whereas in the matched ECMO group, the median survival was 13 days (P<0.001 by the log-rank test). For participants in cohort 2 and the matched ECMO group, the median survival was 144 days and 10 days, respectively (P<0.001 by the log-rank test). Serious adverse events in cohort 1 and cohort 2 included major bleeding (in 42% and 50% of patients, respectively), infection (in 63% and 50%), and stroke (in 29% and 29%). CONCLUSIONS Our trial showed that survival rates were significantly higher with the ventricular assist device than with ECMO. Serious adverse events, including infection, stroke, and bleeding, occurred in a majority of study participants. (Funded by Berlin Heart and the Food and Drug Administration Office of Orphan Product Development; ClinicalTrials.gov number, NCT00583661.) N Engl J Med 2012;367:532-41. DOI: 10.1056/NEJMoa1014164 Copyright © 2012 Massachusetts Medical Society. 532 n engl j med 367;6 nejm.org august 9, 2012 The New England Journal of Medicine Downloaded from nejm.org by Shaun Custard on August 9, 2012. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved. Fraser CD Jr, Jaquiss R, Rosenthal D, Humpl T, Canter C, Blackstone E, Naftel D, Ichord R, Bomgaars L, Tweddell J, Massicotte M, Turrentine M, Cohen G, Devaney E, Bennett Pearce F, Carberry K, Kroslowitz R, Almond C. Prospective trial of a pediatric ventricular assist device. N Engl J Med 2012; 367:532-541. 2 13 14 DEPARTMENT OF SURGERY DEPARTMENT OF SURGERY B erlin Heart EXCOR ® Pediatric Clinical Trial – Outcomes Smaller Patients (body surface area < 0.7 m2) Median duration of support Longest time a child was supported by the device Larger Patients (body surface area ≥ 0.7 m2 but < 1.5 m2) Median duration of support Longest time a child was supported by the device Berlin Heart EXCOR® Pediatric ECMO 28 days 5 days 174 days 21 days At 174 days, 88% of patients had been successfully transplanted At 21 days, 25% of patients had died Berlin Heart EXCOR® Pediatric ECMO 43 days 5 days 192 days 28 days At 192 days, 92% of patients had been successfully transplanted At 30 days, 33% of patients had died These data demonstrate that the Berlin Heart EXCOR® Pediatric improves the chances of survival for children of all ages as compared to ECMO support. 90% Over the course of the study, which included collaborating investigators from Harvard, Stanford and other prestigious institutions, patients did extremely well. In the primary cohort, more than 90% of children were successfully bridged to transplantation or recovery. 15 16 DEPARTMENT OF SURGERY Department of Surgery Research Seed Grants Texas Children’s Hospital recently issued $350,000 in surgical seed grant awards to physicians in the Department of Surgery in order to fund the following research projects. Congenital Heart Surgery: Iki Adachi, M.D. Ex Vivo Perfusion of Donor Lungs before Transplantation: Development of “Pediatric-Specific System” Donor lungs suitable for transplant are the rarest of all transplanted organs, and organ shortage is most serious in small children. To expand the donor pool, ex vivo lung perfusion (EVLP) has been developed, which can be used to assess and even improve the function of marginal lungs prior to implantation. However, systems are currently available only for adult lungs. This project seeks to develop a pediatric-specific EVLP system for deployment in Texas Children’s Lung Transplant Program. To date, Dr. Adachi has successfully developed a pediatric EVLP system and tested its feasibility with lungs from infant pigs. He plans to proceed to the preclinical trial phase, where the pediatric EVLP system will be used for human donor lungs that have not been accepted by any programs and thus are being discarded. Neurosurgery: Andrew Jea, M.D. Axonal Growth Stimulation by Carbon-Based Conductive Nanomaterials in Vitro The main goal of this research seed grant is to determine the best electrical stimulation window for primary cortical neuron cells. The focus is on preparation of graphene-based biomaterials for tissue engineering following spinal cord injury (SCI) and in vivo experiments using graphene-based biomaterials to regenerate damaged tissue. Development of an automated computational image analysis algorithm has begun, which will increase the efficiency of the quantitated morphometric image analysis and remove the human element. Dr. Jea is also moving forward in testing graphene in an in vivo spinal cord injury model. Otolaryngology: Mary Frances Musso, D.O. Magnetic Resonance Imaging in Children with Sleep Apnea This research seed grant focuses on pediatric obstructive sleep apnea (OSA), which can result in serious morbidity with associated growth problems, pulmonary hypertension, systemic hypertension, cor pulmonale and neuropsychological dysfunction. This study aims to characterize structural brain DEPARTMENT OF SURGERY changes in children with OSA in comparison to control children using MRI, study the relation of MRI results and basic cognition and behavior and evaluate the relation of MRI results to clinical polysomnography parameters. Preliminary results demonstrate intermittent hypoxemia associated with OSA in children alters brain morphology and is more pronounced in patients with severe OSA. Currently no impairment of overall cognitive function has been noted. Pediatric General Surgery: Eugene Kim, M.D. GCSF: Friend or Foe in the Treatment of Neuroblastoma Neuroblastoma is the most common abdominal solid tumor in children. It is a highly aggressive malignancy with poor survival in children with high-risk disease, the majority of whom succumb to tumor relapse. One potential candidate for tumor recurrence is cancer stem cells, considered to be “super” cancer cells which are resistant to chemotherapy and radiation and able to form whole new tumors from a single cell. Dr. Kim, in collaboration with Jason Shohet, M.D., Ph.D., Chair of the Neuroblastoma Program at Texas Children’s Cancer Center, has recently completed the identification, isolation and characterization of a novel subpopulation of neuroblastoma that appear to act as cancer stem cells. This subpopulation of cells exclusively expresses the receptor CD114, and future efforts will be focused on targeting this cell population to inhibit tumor formation and metastasis. Pediatric General Surgery: Jed G. Nuchtern, M.D. Genomic Anatomy of Chemotherapy-Resistant Neuroblastoma Despite intensive multi-modality therapy, the 10-year survival rate for highrisk neuroblastoma patients is a disappointing 15 percent. Current efforts are focused on developing novel therapeutic strategies to improve the prognosis of higher-stage neuroblastoma patients. The goal of this research seed grant is to interrogate the genome of tumor tissue to identify genetic/genomic changes that are enriched in the tumor samples after induction therapy as a method to pinpoint the mechanisms of chemotherapy resistance. Using laser capture microdissection, Dr. Nuchtern is able to isolate neuroblasts before and after induction therapy and identify genomic alterations in chemotherapy-resistant neuroblastoma tumor cells using whole exome sequencing and array comparative genomic hybridization of genomic DNA. Complete sets of genomic DNA have been collected from four patients and are currently undergoing genomic analysis. In addition, the research team continues to harvest genetic material from the remaining patients in our tumor bank. 17 18 DEPARTMENT OF SURGERY Pediatric General Surgery: Oluyinka Olutoye, M.D., Ph.D. Effect of Fetal Anesthesia on the Developing Ovine Brain The purpose of this study is to evaluate the effect of dose and duration of anesthesia on brain cell death in the fetus. The results of the initial phase of the study demonstrate that gestational age-dependent variability exists in the degree of neuroapoptosis observed as part of the baseline brain development, and it is most pronounced in the dentate gyrus. The fetal brains exposed to isoflurane anesthesia in utero had a greater degree of neuroapoptosis most prominently in the dentate gyrus of the hippocampus. These initial findings are encouraging and serve as the basis for ongoing studies to assess the effect of anesthetic dose, duration and gestational age on fetal neurotoxicity. Pediatric General Surgery: Sanjeev Vasudevan, M.D. The Role of DUSP26 in Neuroblastoma Tumor Growth and Chemosensitivity The main goal of this research seed grant is to establish the protein phosphatase, DUSP26, as an oncogene in neuroblastoma responsible for tumor growth and chemoresistance. To date, Dr. Vasudevan has developed multiple siRNA sequences against DUSP26 which successfully knock down expression of DUSP26 in neuroblastoma cell lines. He has seen a significant defect in proliferation both in vitro and in vivo in these cells, showing that DUSP26 expression plays a critical role in neuroblastoma tumor growth. These experiments thus far have established DUSP26 as an important oncogene in neuroblastoma. D E P A R T M E N T O F A N E S T H E S I O L O GY Department of Anesthesiology Last year, our team of highly skilled and experienced pediatric anesthesiologists completed more than 35,000 cases, spanning the spectrum from simple outpatient procedures to complicated, 12-hour-plus surgeries. Our goal is to ensure each child has a safe, pain-free and stressfree experience, whether it is surgery in an operating room or a procedure or test completed elsewhere in the hospital. This includes mobile, bedside sedation in patients’ rooms, which can help reduce anxiety and stress during minor surgical procedures. Additionally, five anesthesiologists worked as part of the Cardiovascular Intensive Care Unit (CVICU) to provide specialized anesthesia services for these complex patients. Anesthesia for children and babies requires specifically designed and sized equipment, and we utilize the very latest in technology, including advanced monitors and near-infrared spectroscopy to measure brain oxygen levels during complex cases. The Department of Anesthesiology is committed to patient care, education and research. We operate one of the leading fellowship programs in the United States, providing training in general pediatric anesthesia and pediatric cardiovascular anesthesia. Our active clinical and basic research programs are involved in more than 20 projects. 19 20 D E P A R T M E N T O F A N E S T H E S I O L O GY We are also dedicated to optimizing safety and surgical outcomes. On a national level, the department participates in several pediatric anesthesia databases that gather and evaluate outcomes data from across the nation to help identify evidence-based protocols and best practices. Within the hospital, our staff partners with surgeons, nurses and operating room staff to provide the best possible surgical care for each child, including presurgical briefings, constant communication during surgery and postoperative debriefing to discuss ongoing care including pain management. T e x as C h i ldren ’ s Hosp i tal W est C ampus The Department of Anesthesia coverage includes urgent, outpatient and inpatient services in five locations at Texas Children’s Hospital West Campus, including all four operating rooms and an outpatient procedure room. This year we implemented new state-of-the-art electronic anesthesia machines throughout Texas Children’s Hospital. These machines enable us to deliver safe and accurate anesthetic gas and ventilation to the smallest patients. Also, they interface with our EPIC Anesthesia Electronic Medical Record for very detailed and accurate recording of all the parameters for the anesthesia record. We are one of the first pediatric anesthesia departments in the United States to have both EPIC Anesthesia Electronic Medical Records (EMR) as well as state-of-the-art anesthesia machines throughout the system in almost all of our locations. With the opening of Texas Children’s Pavilion for Women, we added bedside surgery coverage for babies who are too fragile to be moved to an operating room. T h i s y ear We became one of the first pediatric anesthesia programs in the United States to completely computerize anesthesia medical records. This comprehensive and accurate data will help ensure the safest and most precise procedures by immediately providing a patient’s detailed medical and anesthesia history. D E P A R T M E N T O F A N E S T H E S I O L O GY Neurodevelopmental Outcomes A multidisciplinary team from pediatric cardiovascular anesthesiology, congenital heart surgery, pediatric cardiology, pediatric intensive care, pediatric radiology, pediatric neurology and developmental pediatrics has enrolled a cohort of 97 neonates undergoing complex cardiac surgery for long term follow-up of neurological events and neurodevelopmental outcomes. Two major papers were written about this study and have been published in Annals of Thoracic Surgery. The first3 won the J. Maxwell Chamberlain Award for the best paper in Congenital Heart Surgery at the 2012 Society of Thoracic Surgeons’ Annual Meeting. This study found that the 20 patients with transposition of the great arteries undergoing the arterial switch operation had a mean cognitive score on the Bayley Scales of Infant Development III of 104.8 ± 15.0, significantly above the reference population mean normal value. In addition, for the very first time, these Texas Children’s Hospital investigators demonstrated an association between preoperative MRI brain injury and later neurodevelopmental outcomes. In the second paper4, the team demonstrated excellent cognitive outcomes at age 12 months in 35 patients undergoing a special cardiopulmonary bypass technique with a protocol for brain monitoring developed by Dean B. Andropoulos, M.D., Charles D. Fraser, Jr., M.D., and E. Dean McKenzie, M.D., in the early 2000s. The cognitive score on the Bayley Scales of Infant Development III was 100.1 ± 14.6 for this group, equal to the population norm. In addition, the investigators demonstrated that longer duration of regional cerebral perfusion was not associated with worse outcomes. This is the largest outcome study ever published in regional cerebral perfusion patients. It demonstrates the safety and efficacy of this technique and the neuromonitoring protocol pioneered at Texas Children’s Hospital. Andropoulos DB, Easley RB, Brady K, McKenzie ED, Heinle JS, Dickerson HA, Shekerdemian L, Meador M, Eisenman C, Hunter JV, Turcich M, Voigt RG, Fraser CD Jr. Changing expectations for neurological outcomes after the neonatal arterial switch operation. Ann Thorac Surg. 2012 Jun 28. [Epub ahead of print] 3 Andropoulos DB, Easley RB, Brady K, McKenzie ED, Heinle JS, Dickerson HA, Shekerdemian LS, Meador M, Eisenman C, Hunter JV, Turcich M, Voigt RG, Fraser CD Jr. Neurodevelopmental outcomes after regional cerebral perfusion with neuromonitoring for neonatal aortic arch reconstruction. Ann Thorac Surg. 2012 Jul 3. [Epub ahead of print] 4 21 D E P A R T M E N T O F A N E S T H E S I O L O GY Magnetic resonance imaging (MRI) as a research tool to help determine the causes of neurodevelopmental outcome problems in congenital heart disease. A. Preoperative sagittal T1 weighted MRI of a 35-week gestational age infant with hypoplastic left heart syndrome. White matter injury (WMI) is present in the periventricular areas (arrows). B. Preoperative axial proton-density T2 weighted image. Again note WMI (arrows). C. Seven day postoperative T1 sagittal MRI after Norwood stage I palliation. Note new intraparenchymal/intraventricular hemorrhage and infarction in the left peritrigonal region (arrow). D. Proton density T2-weighted image. Again note WMI and new hemorrhage. This research has helped determine cardiopulmonary bypass, neuromonitoring, and other techniques that result in improved neurodevelopmental outcomes at age 12 months. 2009 2010 2011 * P ro j ected Anesthesia case volumes include anesthesia administered by Texas Children’s Hospital physicians at Texas Children’s Hospital locations. 36,643 35,210 2008 32,463 2007 30,757 28,366 D epartment of A nest h es i a C ases by Year 28,247 22 2012* D E P A R T M E N T O F A N E S T H E S I O L O GY 2012 * D epartment of A nest h es i a C ases by Location* 10 4 1, WE S T C A M P U S 53 CON G E NI TA L H E A RT S U RG E RY 926 CLIN IC A L C A R E C E NTE R 1, 4 6 2 WE S T TO W E R 319 10 6 Anesthesia procedures in Texas Children's Hospital operating rooms ,9 20 7, 5 9 0 4 4 9, 7 31 75 18 3, Sedation and anesthesia procedures in other Texas Children's Hospital areas RA DIOLOGY C A NC E R C E NTE R PATI ENT S U NDERGOING PROCEDU RES (PACU ) CA RDIAC CAT HET ERIZAT ION LA B S GA ST ROINT EST INAL PROCEDU RE SU IT E INT ENSIV E CARE U NIT S M OB ILE SEDAT ION * P ro j ected 23 24 D E P A R T M E N T O F A N E S T H E S I O L O GY D ean B . A ndropoulos , M . D . , is Chief of Anesthesiology at Texas Children’s Hospital and Professor of Anesthesiology and Pediatrics at Baylor College of Medicine. He received his medical degree at the University of California at San Diego. His residencies in Pediatric Medicine and Anesthesiology were both at the University of California at San Francisco. In addition, Dr. Andropoulos earned a Masters of Science degree in Healthcare Management from the Harvard School of Public Health. His research focus is neurological monitoring, protection and outcomes in neonates undergoing complex open heart surgery, for which he has received National Institutes of Health (NIH) funding. He is the editor of two major textbooks, Anesthesia for Congenital Heart Disease, 2nd Edition; and Gregory’s Pediatric Anesthesia, 5th Edition. He is also co-principal investigator at Texas Children’s Heart Center® for the NIH-funded Pediatric Heart Network Core Clinical Center. CONGENITAL HEART SURGERY Congenital Heart Surgery The Congenital Heart Surgery Division provides customized and comprehensive surgical care for all aspects of pediatric and congenital heart disease. Texas Children’s Heart Center performs nearly 800 surgical procedures annually with outcomes among the best in the nation. Additionally, the Heart Center is consistently ranked among the top pediatric cardiology and heart surgery programs in the nation by U.S.News & World Report. We treat children of all ages, including preterm and low-birth-weight newborns, and we personalize treatments and procedures to best suit the situation of each child and family. This tailored approach includes cardiopulmonary bypass and neuroprotection strategies focused on the patient’s condition and needs, which helps to achieve optimal outcomes. 25 26 CONGENITAL HEART SURGERY Our highly specialized procedures include: • Arterial switch procedure • Atrial septal defect and ventricular septal defect closures • Atrioventricular canal repair • Cardiac valve repair/replacement • Double-switch procedures • Heart and lung transplantations and ventricular assist devices • Hypoplastic left heart syndromes • Repair of anomalous coronary artery • Repair of Ebstein’s anomaly • Single ventricle procedures • Tetraology of Fallot repair Our dedicated clinical team includes operating room nurses, nurse practitioners, registered nurse first assists and nurse coordinators; surgical and perioperative care technicians; perfusionists and perfusion assistants; and physician assistants. Texas Children’s Heart, Lung and Heart-Lung Transplant Programs, among the nation’s largest and most successful, are also part of the Congenital Heart Surgery Division. T e x as C h i ldren ’ s Hosp i tal W est C ampus For the convenience of our patients who live in the west Houston area, the Congenital Heart Surgery Division holds a monthly surgical consult clinic at Texas Children’s Hospital West Campus. CONGENITAL HEART SURGERY A main area of focus continues to be the Pediatric Cardiac Bioengineering Laboratory, a joint effort of Texas Children’s Hospital and Rice University led by Jeffrey Jacot, Ph.D. Committed to developing innovative therapies that translate into clinically relevant and beneficial solutions for our patients, this exciting field of research holds great potential. Research is concentrated on investigating the influences of biophysical cues such as stress, strain, shear, substrate stiffness and electrical stimulation on the development and maturation of heart cells and tissues. Dr. Jacot received a grant from the National Institutes of Health, with K. Jane Grande-Allen, Ph.D., as the co-principal investigator, in order to organize and run a symposium on Tissue Engineering for Pediatric Applications. This symposium was held as a pre-conference workshop prior to the Tissue Engineering and Regenerative Medicine International Society (TERMIS) in December 2011. T HI S Y E A R The Berlin Heart EXCOR® Pediatric Ventricular Assist Device (VAD), the only VAD designed specifically for use in children, received FDA approval. Charles D. Fraser, Jr., M.D., Surgeon-in-Chief and Donovan Chair and Chief of Congenital Heart Surgery, served as the national principal investigator for the study leading to the approval and was invited to present the findings to an FDA advisory panel. For more information on this groundbreaking trial, please see page 13. 27 CONGENITAL HEART SURGERY 2009 2010 O P E R AT I N G RO O M C A S E S 2011 1,421 771 1,309 837 834 1,422 1,456 C on g en i tal Heart S ur g er y O perat i n g R oom C ases and C l i n i c V i s i ts by Year 912 28 2012* CLINIC VISITS * P ro j ected Total operating room volumes include heart and lung transplantations. Operating room case volumes and clinic visits include procedures and outpatient visits completed by Texas Children’s Hospital physicians at Texas Children’s Hospital surgical locations. CONGENITAL HEART SURGERY M ortal i tes b y R A C H S - 1 C lass i f i cat i on in 2011 PRIMARY PROCEDURE NUMBER OF NUMBER OF DISCHARGE PROCEDURES MORTALITIES % MORTALITY STS NATIONAL BENCHMARK Total for Risk Category 1 58 0 0.0% 0.6% Total for Risk Category 2 233 2 0.9% 0.8% Total for Risk Category 3 185 2 1.1% 3.4% Total for Risk Category 4 44 2 4.5% 6.8% Total for Risk Category 5-6 25 2 8.0% 15.5% 545 8 1.5% 3.0% TOTAL The Risk Adjustment in Congenital Heart Surgery (RACHS-1)5 categorization is a widely used risk stratification model used to analyze outcomes in congenital heart surgery. The most common surgeries for congenital heart defects are stratified into six risk categories. Surgeries with higher risk are placed in higher categories with category six representing congenital heart surgeries associated with the greatest risk. 1.5% Overall risk-adjusted hospital mortality rate for our program in 2011 was 1.5%.6 Data collected by the Society of Thoracic Surgeons (STS) shows the national hospital discharge mortality rate at 3.0%.7 5 Jenkins, KJ, Gauvreau K, Newburger JW, et al., Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg, 2002;123:110-8. 6 007-RACHS-1 Index Surg CHD Volume. Data pulled January 21, 2012. 7 Society of Thoracic Surgeons Data Harvest Report. January - December 2010. 29 30 CONGENITAL HEART SURGERY O utcomes F ollow i n g A ort i c V alve R epa i r and R eplacement i n C h i ldren Surgical treatment of aortic valve (AV) diseases in childhood involves complex decisions particularly in very small patients, and there is no consensus regarding the optimum surgical option. The surgical outcomes for this disease at Texas Children’s are among the best in the nation. Total operations 97 AV repairs 188 AV replacements 68 autograft 74 homograft 36 mechanical 10 bioprosthetic Median age at first operation 7 years (range: 1 day to 18 years) Gender Immediate failure of valve repair (within 24 hrs) requiring replacement Males = 154 (64%) 2 (2%) patients Survival 98% for AV repairs 97% for AV replacements Reoperations at last follow-up 8 17% for AV repairs 16% for AV replacements Survival at last follow-up 97% for AV repairs 96% for AV replacements Depictions of modes of aortic valve dysfunction that may be surgically correctable including cusp restriction and prolapse. 8 Average follow-up time was 4 years (range: 8 days to 15 years). CONGENITAL HEART SURGERY In the setting of a subaortic ventricular septal defect, the associated aortic valve cusp may be subject to distortion and prolapse related to turbulent flow. The corresponding cusp elongation and prolapse may progress to significant aortic valve incompetence. In the setting of severe aortic valve cusp distortion, symmetric leaflet reduction may be required as noted in this illustration. Subcommissural sutures also aid in improving the zone of coaptation with adjacent cusps. 31 32 CONGENITAL HEART SURGERY C h arles D . F raser , J r . , M . D . , is Surgeon-in-Chief and Chief of the Division of Congenital Heart Surgery at Texas Children’s Hospital. His academic appointments include Professor of Surgery in the Michael E. DeBakey Department of Surgery (tenured) at Baylor College of Medicine, Professor of Pediatrics at Baylor College of Medicine and Adjunct Professor of Bioengineering at Rice University. Dr. Fraser holds the Susan V. Clayton Chair in Surgery at Baylor College of Medicine and the Donovan Chair in Congenital Heart Surgery at Texas Children’s Hospital. Dr. Fraser has a clinical appointment at the Texas Heart Institute where he serves as Director of the Adult Congenital Heart Surgery Program. Dr. Fraser’s extensive education began as an undergraduate at the University of Texas at Austin, where he graduated with honors in mathematics. He received his medical degree with honors from the University of Texas Medical Branch at Galveston. His residency and fellowship training took place at The John Hopkins Hospital. He completed additional fellowship training in Congenital Heart Surgery at the Royal Children’s Hospital in Melbourne, Australia. After joining the faculty at Cleveland Clinic, Dr. Fraser was recruited to Texas Children’s Hospital in July of 1995 to establish a dedicated pediatric congenital heart surgery program. Since that time, he and his team have performed corrective operations in more than 10,000 children and adults with congenital heart disease. DENTAL Dental The Dental Division at Texas Children’s Hospital performs more than 800 procedures each year to ensure patients with special needs or complex medical diagnoses receive the dental care they need. Dental patients are treated as outpatients, inpatients or in the operating room. With expertise in a full range of procedures, our team coordinates each patient’s care with its pediatric subspecialists. Sometimes dental treatment, such as removal of teeth or replacement of fillings, is needed before surgery or anesthesia can take place or other health care needs can be addressed. Orthodontia is provided for children with congenital craniofacial anomalies and/or cleft palates. In addition, we ensure that the annual dental needs, such as prophylaxis or fillings, of children with special needs are met. 33 DENTAL We collaborate with the following surgical and medical subspecialties at Texas Children’s Hospital to provide optimum care for patients, including international patients: • Nephrology • Neurology • Texas Children’s Heart Center • Texas Children’s Cancer Center M ult i d i sc i pl i nar y team The Dental Division participates monthly in the multidisciplinary Craniofacial Clinic to address genetic abnormalities of the face and head. This collaborative effort brings together experts from dermatology, genetics, neurosurgery, otolaryngology, plastic surgery, radiology and speech therapy. D ental O perat i n g R oom C ases and C l i n i c V i s i t 2007 2008 O P E R AT I N G RO O M C A S E S 2009 2010 2011 2 , 354 804 847 2,472 2,596 778 2,559 810 759 2,593 2,758 by Year 748 34 2012* CLINIC VISITS * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. DENTAL A . B ruce C arter , D . D . S . , is Chief of the Dental Division and Dental Clinic at Texas Children’s Hospital. He received his doctorate of Dental Surgery at the University of Texas Health Science Center at Houston, where he also received his Pedodontic Certificate. After a solo practice and teaching at his alma mater, he joined Texas Children’s Hospital as the Dental Clinic Chief in 1984. He is member of the American Board of Pediatric Dentistry Diplomats, the Greater Houston Dental Society, the Texas Dental Association, the American Dental Association and the American Academy of Pediatric Dentistry. In conjunction with a grant from the National Institutes of Health, Dr. Carter studied and published several articles on the oral manifestations and health of pediatric HIV patients. 35 36 N eurosur g er y Neurosurgery The Neurosurgery Division at Texas Children’s Hospital, recently ranked 5th nationwide in Neurology and Neurosurgery by U.S.News & World Report, is one of the most active and experienced pediatric neurosurgery programs in the nation. We complete more than 900 procedures each year to address a broad range of neurological disorders in infants, children and young adults. Our board-certified pediatric neurosurgeon-scientists provide surgical treatment of neurological diseases including problems of the brain, spine and peripheral nervous system. We are committed to discovering groundbreaking diagnosis and treatment approaches and to training the next generation of expert neurosurgeons. N eurosur g er y We take a multidisciplinary approach to care, working closely with Texas Children’s Cancer Center, Texas Children’s Fetal Center, the Comprehensive Epilepsy Program, neurology, adolescent medicine, developmental pediatrics, interventional neuroradiology, otolaryngology, plastic surgery, physical medicine and rehabilitation and urology. Conditions treated and surgical procedures include: • Congenital malformations of the brain and spine • Craniofacial malformations • Epilepsy • Hydrocephalus • Movement disorders • Spinal deformities • Tumors of the brain, spine and peripheral nerves • Vascular malformations of the brain and spine M ult i d i sc i pl i nar y team Texas Children’s Hospital has developed extensive screening and diagnostic algorithms for pregnancies with myelomeningocele (spina bifida). Spina bifida occurs in three of every 10,000 live births in the United States, and the standard of care is neurosurgical closure of the defect in the first days of life. Earlier this year, the Neurosurgery Division worked closely with a multidisciplinary team from Texas Children’s Fetal Center, pediatric general surgery, anesthesiology, neonatology, radiology, cardiology and more to perform the hospital’s first in utero surgery for treatment of spina bifida. The baby’s mother went into labor nearly 11 weeks after fetal closure and delievered by cesarean section. The surgery was a success, and both mother and baby are doing well. 37 N eurosur g er y 2008 O P E R AT I N G RO O M C A S E S 2009 2010 2011 969 4,975 915 4,678 966 4,135 930 3,261 787 2,373 2007 5, 388 N eurosur g er y O perat i n g R oom C ases and C l i n i c V i s i ts by Year 672 38 2012* CLINIC VISITS * P ro j ected Operating room case volumes and clinic visits include procedures and outpatient visits completed by Texas Children’s Hospital physicians at Texas Children’s Hospital surgical locations. T HI S Y E A R The Neurosurgery Division continues to use real-time MRI-guided thermal imaging and laser technology to destroy lesions in the brain that cause epilepsy. This procedure is a safer and less invasive approach than craniotomy for some patients, and it has a high rate of success in reducing or eliminating seizures in patients ages 5 to 15. To date, the Neurosurgery Division has completed 15 stereotactic laser ablation procedures, and all patients are currently seizure free. In collaboration with Rice University, the division is investigating neuroregeneration, accomplished by growing neurons on nanomaterials, as a treatment modality for chronic residual effects of spinal cord injuries. Funding sources include the U.S. Army, the Neurosurgery Research and Education Fund and Texas Children’s Hospital. N eurosur g er y T h omas G . L uerssen , M . D . , F . A . C . S . , F . A . A . P . , is Chief of Neurosurgery and Chief Quality Officer Surgery at Texas Children’s Hospital. He is also Professor of Neurological Surgery and Director of the Pediatric Neurosurgery Program in the Department of Neurosurgery at Baylor College of Medicine. Dr. Luerssen attended medical school at Indiana University and completed his residency in Neurosurgery at Indiana University Medical Center. He completed fellowship training at Children’s Hospital of Philadelphia and then joined the faculty at the University of California San Diego. His clinical and research focus was traumatic brain injury in childhood. Later, Dr. Luerssen returned to Indiana University and spent 18 years as Director of the Pediatric Neurosurgery Service at the James Whitcomb Riley Hospital for Children. In 2006, he was recruited to Texas Children’s Hospital to be Chief of Neurosurgery and was named Chief Quality Officer Surgery in 2009. Dr. Luerssen is the past Chairman of the Joint Section on Pediatric Neurological Surgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons and past President of the American Society of Pediatric Neurosurgeons. He is currently Vice Chairman of the American Board of Pediatric Neurological Surgery. 39 40 O p h t h almolo g y Ophthalmology The Ophthalmology Division at Texas Children’s Hospital provides the highest-quality surgical care for anomalies, disorders and injuries of the eyes. Since its inception, the Ophthalmology Division has grown into one of the premier pediatric ophthalmology surgery programs in the nation, with exceptional expertise, depth and quality of services, and patient volumes. We provide individualized treatment for a range of ophthalmology disorders, including strabismus (mis-aligned eyes), retinopathy of prematurity, tear duct obstruction, retinal detachment and genetic eye diseases, ptosis, retinoblastoma and orbital tumors and other anomalies. The Ophthalmology Division is one of the few programs in the nation with expertise in vitreoretinal surgery for children. O p h t h almolo g y Our division includes experts in: • Cataracts • Craniofacial abnormalities • Glaucoma • Inpatient ophthalmology • Neuro-ophthalmic disorders • Ophthalmologic plastic surgery • Pediatric and adult strabismus • Retinoblastoma • Treatment of eye disorder in children with brain tumors As one of only two programs in the United States to offer refractive surgery (PRK laser) for children, we collaborate with Baylor College of Medicine to achieve positive results with near-sightedness, far-sightedness and astigmatism. Approximately 90 percent of our patients who have this procedure improve best vision by at least two lines on the standard eye chart. Over the past year, 11 articles were published in peer-reviewed publications, and numerous presentations were made nationally and internationally. Our physician-scientists are also breaking new ground in multiple areas of pediatric ophthalmology research. Lingkun Kong, M.D., Ph.D., a post-doctoral fellow, was involved in several studies published in major journals, including management of strabismus in children with cataracts, childhood blindness, antibiotic therapy in ureaplasma sepsis, placenta ureaplasma in high-risk neonates and retinopathy of prematurity. Pending projects include investigation of levodopa for residual amblyopia, hyperopia, amblyopia and development of an electrophysiology lab. T e x as C h i ldren ’ s Hosp i tal W est C ampus Outpatient, inpatient and emergency surgical procedures are provided at Texas Children’s Hospital West Campus, and clinic is conducted each weekday. 41 O p h t h almolo g y M ult i d i sc i pl i nar y team We are members of the Retinoblastoma Center of Houston, a multi-institution, multidisciplinary consortium dedicated to research and innovative treatment to fight this dangerous cancer. The group brings together experts in genetics, general surgery, ophthalmology and oncology from several hospitals in the Texas Medical Center. Additionally, we are part of the Neuro-oncology Team at Texas Children’s Hospital, a multidisciplinary team of surgeons and medical physicians with expertise in the management of complex cancers that involve the central nervous system. We also play an active role on the Hearing Team at Texas Children’s Hospital, which provides management of disorders that can result in hearing and vision abnormalities in children. TEXAS CHILDREN’S HOSPITAL 1,283 2011 2012* 1,218 65 2010 1,130 1,177 2009 47 2008 1,205 2007 1,105 1,139 O p h t h almolo g y O perat i n g R oom C ases by Year 1,039 42 TEXAS CHILDREN’S HOSPITAL WEST CAMPUS * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. O p h t h almolo g y 2,346 2010 2011 16,158 10,590 2,985 2,583 2,230 97 1,705 11,415 10,499 13,742 14,550 O p h t h almolo g y C l i n i c V i s i ts by Year 2012* TEXAS CHILDREN’S HEALTH CENTERS TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. T HI S Y E A R The Ophthalmology Division began performing the following procedures this year: situ dissection for strabismus, performed with topical anesthesia, which allows precise titration of surgical dose with intraoperative patient feedback. The technique facilitates surgical precision through minimized tissue manipulation. • In • Periosteal • Rectus eye muscle transposition to treat nystagmus (shaking of the eye). muscle posterior displacement for vertically incommitant strabismus. 43 44 O p h t h almolo g y D av i d K . C oats , M . D . , is Chief of Ophthalmology at Texas Children’s Hospital and Professor of Ophthalmology and Pediatrics at Baylor College of Medicine. He received his medical degree from Texas Tech University School of Medicine in 1987, followed by an internship in South Carolina and residency at the Storm Eye Institute at the Medical University of South Carolina. He completed a fellowship in Pediatric Ophthalmology and Adult Strabismus at Indiana University in Indianapolis, Indiana in 1994 and joined the staff at Baylor College of Medicine in 1996. Dr. Coats is past Chair of the Ophthalmic Knowledge and Assessment Program (OKAP), on the Board of Directors of the Pan American Association of Ophthalmologists and PresidentElect of the Texas Ophthalmologic Association. O rt h opaed i cs Orthopaedics The Orthopaedics Division at Texas Children’s Hospital has extensive expertise in treatment of all types of bone, neuromuscular and spine disorders and injuries. Consistently ranked by U.S.News & World Report as a leading orthopaedic center for children, we treat a variety of orthopaedic injuries and conditions, from minor fractures to complex problems. More than 40 percent of the surgical procedures completed in Texas Children’s Level 1 Trauma Center in 2011 were orthopaedic-related. 45 46 O rt h opaed i cs Our surgical expertise includes advanced approaches to: • Back problems including scoliosis, kyphosis, spondylolisthesis and spondylolysis • Benign and malignant bone tumors • Congenital deformities such as clubfoot • Fractures, dislocations and residual effects of trauma such as malunion and growth arrest • Hip problems including developmental dysplasia of the hip (DDH), slipped capital femoral epiphysis (SCFE), Legg-Calves-Perthes disease and femoro-acetabular impingement (FAI) • Leg-length inequality and other limb alignment problems such as bow legs (Blount’s disease) • Metabolic bone disease • Neuromuscular disorders including cerebral palsy, myelomeningocele (spina bifida), Duchenne and other muscular dystrophies • Skeletal dysplasias • Sports injuries including knee ligament and meniscus problems and patella-femoral problems Our surgeons work closely with experienced mid-level providers in order to provide the highest level of patient care in the clinic and operating rooms. These mid-level providers receive six months of pediatric-fracture-specific training at Texas Children’s and are closely supervised by Orthopaedic Division faculty. Additionally, a high-tech digital imaging system allows instant consultation with a physician when needed. Our comprehensive support team also includes physical and occupational therapists, cast technicians, social workers and child life specialists. Working in close concert with the recently established Texas Children’s Surgical Outcomes Center, the Orthopaedic Division is currently monitoring outcomes and procedures for supracondylar humerus fractures and spinal surgery in order to analyze patient outcomes and improve our already high standard of treatment. O rt h opaed i cs The Orthopaedics Division’s specialized clinics include: • Sports Medicine Program: Provides diagnosis, evaluation and treatment for pediatric and young adult athletic-related injuries and conditions. • Fracture Clinic: Our physicians partner closely with highly trained mid-level providers to repair more than 120 broken bones each week. • Adolescent and Young Adult Hip Clinic: The only one of its kind in the region, this clinic focuses on diagnosis and treatment of hip conditions that can lead to pain, disability and early onset arthritis. • Scoliosis Clinic: Highly specialized surgeons perform procedures to correct this skeletal deformity. T e x as C h i ldren ’ s Hosp i tal W est C ampus The Orthopaedics Division, which currently operates the busiest outpatient surgery clinic at Texas Children’s Hospital West Campus, provides both inpatient and emergency surgery coverage. M ult i d i sc i pl i nar y team The Orthopaedic Division participates in several multidisciplinary clinics, including: • Orthopaedic infection clinic with infectious disease • Skeletal dysplasia clinic with genetics • Spina bifida clinic with neurosurgery, pediatric general surgery and physical medicine • Spasticity clinic with neurology and physical medicine 47 O rt h opaed i cs TEXAS CHILDREN’S HOSPITAL 2 ,182 356 1,826 2,093 2010 1,998 2009 95 2008 1,844 2007 1,918 1,803 O rt h opaed i c S O perat i n g R oom C ases by Year 1,601 48 2011 2012* TEXAS CHILDREN’S HOSPITAL WEST CAMPUS * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. O rt h opaed i cs 21,883 4,260 4,650 3,649 3,792 131 6,998 10,235 19,417 11,508 12,429 16,352 O rt h opaed i c S C L I N I C V I S I T S by Year 2010 2011 2012* TEXAS CHILDREN’S HEALTH CENTERS TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. W i ll i am A . P h i ll i ps , M . D . , Chief of Orthopaedics at Texas Children’s Hospital and Professor of Orthopaedic Surgery and Pediatrics at Baylor College of Medicine. He graduated from Notre Dame and received his medical degree from the University of Chicago Pritzker School of Medicine. Dr. Phillips is a member of the American Academy of Orthopaedic Surgeons (Fellow), American Academy of Pediatrics (Fellow), American Orthopaedic Association, Scoliosis Research Society (Fellow), Pediatric Orthopaedic Society of North America and the American College of Surgeons. Dr. Phillips travels around the country lecturing on back problems in children and other orthopaedic issues to primary care physicians. 49 50 O T O L A R Y N G O L O GY Otolaryngology The Otolaryngology Division at Texas Children’s Hospital provides advanced surgical and medical care for the entire spectrum of ear, nose, throat, and head and neck diseases and disorders. In addition to complex procedures, the fellowship-trained physicians in the division complete a high number of more common surgeries such as tonsillectomies and insertion of ear tubes. Over half of surgeries done each year are to address these routine problems. O T O L A R Y N G O L O GY Surgical focus also includes: • Airway reconstruction • Chronic ear diseases and hearing loss • Cleft lip and cleft palate • Congenital and acquired diseases of the aerodigestive tract • Cochlear implantation • Disorders of the ears, tonsils and adenoids • Genetic syndromes and malformations of the head, neck and airway • Head and neck masses, congenital and acquired • Sinus and nose disease • Sleep apnea State-of-the-art audiology and speech diagnostic and therapeutic services are also offered. To advance the diagnosis and treatment of children and babies with disorders of the ear, nose or throat, our physicians are involved in research projects concerning hearing, cochlear implantation, sleep apnea, neck masses and vocal fold mobility. In addition, we are participating in a National Institutes of Health (NIH) grant to study cochlear implants in children with multiple disabilities as well as a Texas Children’s Hospital-funded study of sleep apnea in children. T e x as C h i ldren ’ s Hosp i tal W est C ampus The Otolaryngology Division provides comprehensive inpatient and outpatient coverage at Texas Children’s Hospital West Campus. 51 52 O T O L A R Y N G O L O GY M ult i d i sc i pl i nar y team The Otolaryngology Division participates in a number of multidisciplinary clinics to address specific disorders. These include: • Cochlear Implant Program: Specialists from otolaryngology; speech, language and learning; audiology; neurology; psychology; and social work evaluate children with profound sensorineural hearing loss and perform surgical cochlear implantation when appropriate. • Aerodigestive Disease Clinic: A team approach for complex patients with breathing, swallowing and eating issues, this clinic brings together physicians from gastroenterology, otolaryngology and pulmonary medicine. • Voice and Swallowing Clinic: This clinic utilizes a collaborative approach to evaluation, diagnosis and treatment of disorders in swallowing and vocalization. Other team members include specialists from audiology, speech, language and learning. • Down Syndrome Clinic: We work with the Meyer Center for Developmental Pediatrics to address otolaryngology issues such as sinus disease, hearing problems and sleep apnea, which are often part of this complex congenital disorder. We also provide otolaryngologic services to the Cleft Lip and Palate Team at Shriner’s Hospital for Children in Houston, Texas. This includes long-term comprehensive care of children with craniofacial anomalies who typically have an increased prevalence of ear and upper airway problems. T h i s y ear The Otolaryngology Division established the Aerodigestive Disease Clinic in 2011 and added the first laryngologist to practice at Texas Children’s Hospital, one of only three pediatric fellowship-trained voice specialists in the nation. We also began offering laryngeal stroboscopy, an innovative way of looking at vibratory characteristics of the vocal chord. O T O L A R Y N G O L O GY 2007 2008 2009 TEXAS CHILDREN’S HOSPITAL 9,838 8,024 8,397 2010 2011 1,814 890 7,507 8,329 7,521 6,494 6,818 O tolar y n g olo g y O perat i n g R oom C ases by Year 2012* TEXAS CHILDREN’S HOSPITAL WEST CAMPUS * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. 53 O T O L A R Y N G O L O GY 19,715 11,709 15,239 2010 2011 3,686 4,320 9,829 2,787 2,623 564 11,214 14,562 O tolar y n g olo g y C l i n i c V i s i ts by Year 2,784 54 2012* TEXAS CHILDREN’S HEALTH CENTERS TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. E llen F r i edman , M . D . Since 1991, she has served as Chief of Otolaryngology at Texas Children’s Hospital and since 2009, has held the Bobby Alford Department Chair in Pediatric Otolaryngology at Baylor College of Medicine. Prior to that, she had hospital appointments at The Children’s Hospital and Harvard Medical School. Dr. Friedman is on the editorial boards of a number of professional journals and has been president of the American Broncho-Esophagological Association and the American Society of Pediatric Otolaryngology. She is currently serving as Director of the American Board of Otolaryngology - Head and Neck Surgery, is a representative for Otolaryngology for the Residency Review Committee, is on the Advisory council for the American College of Surgeons and is President of the Medical Staff at Texas Children’s Hospital. Among many professional honors, she was named the 2010 recipient of the Arnold P. Gold Foundation Award for Humanism in Medicine, which honors compassion and empathy in the delivery of patient care. Just recently, Dr. Friedman was recognized by the Baylor College of Medicine Academy of Distinguished Educators with the Fulbright and Jaworski Faculty Excellence Award in Teaching and Evaluation. P ed i atr i c and A dolescent G y necolo g y Pediatric and Adolescent Gynecology One of the few established programs for surgical treatment of pediatric and adolescent gynecologic disorders in the United States and the only such program in Texas, the Pediatric and Adolescent Gynecology Division at Texas Children’s Hospital is committed to providing the highest level of clinical care, research and education. Part of the Obstetrics and Gynecology Department at Baylor College of Medicine and Texas Children’s Hospital, we offer personalized treatment for common and rare gynecological problems in patients ranging from newborns to 21 years old. Specialties include vaginal trauma, congenital anomalies and adnexal cysts or masses. 55 56 P ed i atr i c and A dolescent G y necolo g y Our fellowship-trained physicians have expertise in a wide range of routine and highly complex medical and surgical procedures, both laparoscopic and reconstructive, including: • Chronic conditions such as endometriosis • Common gynecologic conditions including ovarian or tubal masses and trauma • Congenital anomalies of the cervix, vagina, uterus and external genitalia • Gynecologic care for chronically ill girls and adolescents • Puberty and menstruation issues As an international referral center, the Pediatric and Adolescent Gynecology Division treats a large population of young women with congenital anomalies of the Mullerian ducts, which result in malformation of the uterus and/or vagina. Depending on the disorder, surgical and nonsurgical treatments as well as counseling are offered to help patients and their families cope with the diagnosis and possible future fertility issues. We operate one of the few fellowship programs in the United States and Canada for pediatric and adolescent gynecology. Committed to improving the lives of children through research, we have published 29 articles in peer-reviewed journals, written six book chapters and presented 32 abstracts in the past five years. T e x as C h i ldren ’ s Hosp i tal W est C ampus Our team of physicians provides a full range of outpatient services at Texas Children’s Hospital West Campus. P ed i atr i c and A dolescent G y necolo g y M ult i d i sc i pl i nar y team Surgeons from the Pediatric and Adolescent Gynecology Division recently partnered with their colleagues in pediatric general surgery and urology in a complex, 13-hour procedure to correct a posterior cloaca, an extremely rare anorectal malformation. It was the first procedure of its kind at Texas Children’s Hospital. Team members participate in multidisciplinary subspecialty clinics, including: • Gender Medicine Team: A collaboration with experts from several areas including endocrinology, genetics, psychology and urology to address disorders of sexual development in an ethical framework. • Anorectal Malformation Clinic: This team of experts, which includes surgeons from general pediatric surgery and urology, performs complex procedures to correct congenital anomalies in which the anus and rectum do not develop properly. • Young Women’s Bleeding Disorders Clinic: In partnership with Texas Children’s Hematology Center, this is one of the few programs in the nation to offer “one-stop” care for gynecologic, hematologic and psychosocial issues for teenagers with menorrhagia and bleeding disorders. T h i s y ear Over the past year, the Pediatric and Adolescent Gynecology Division increased physician coverage at Texas Children’s Hospital West Campus and participated in more than 25 ongoing research projects. These include investigation of low-dose subcutaneous depot medroxyprogesterone acetate injections or hormonal implants in adolescents, outcomes of office management of lichen sclerosus, and clinical and surgical outcomes in pediatric and adolescent gynecology. 57 58 P ed i atr i c and A dolescent G y necolo g y Adnexal Torsion Outcomes Adnexal torsion (AT) is the fifth most common gynecologic emergency. Clinical symptoms are the most important indicators and delaying diagnosis could compromise ovarian function. Recently the Pediatric and Adolescent Gynecology Division completed a study9 to determine the association between use of emergency room (ER) pain medications and AT and which clinical and sonographic characteristics correlated with AT. Total surgical cases 75 from the abdominal pain cohort (N=302) underwent surgery for presumptive AT 70.9% nausea/vomiting 11.3% fever 64.1% leukocytosis Overall incidence 18.2% (N=55) Mean age 11.7 years (±3.05) Mean ovarian size Route of pain medicine 6.02 cm (±2.02) There was no statistically significant difference in the incidence of AT (p=0.835) based on the route (IV versus oral) of pain medication Patients that received IV morphine were more likely to have AT (p=<0.001) Cases with fallopian tube torsion without ovarian torsion Cases of ovarian torsion with asymmetric ovaries and/or abnormal Doppler flow on ultrasound Salvage rate 10 90% containing a paratubal/paraovarian cyst 100% 23% had peripherally-placed follicles Cases with abnormal ovarian Doppler flow on ultrasound were more likely to have ovarian torsion rather than fallopian tube torsion (p=<0.001) 92.7% Santos, XM, Sokkary, N, Bercaw-Pratt, JL, Dietrich, JE. Association between use of pain medication, ultrasound findings and adnexal torsion among young females presenting with acute abdominal pain. Journal of Pediatric and Adolescent Gynecology, Vol. 24, No. 2. April 2011, pp. e59. 9 P ed i atr i c and A dolescent G y necolo g y C onclus i ons The clinical presentation for cases of AT can mimic other surgical and nonsurgical causes of acute abdominal pain. The requirement of IV morphine for pain management in cases of abdominal pain with abnormal adnexa on ultrasound should raise the suspicion for AT. In cases of acute AP with sonographic findings of paraovarian/ paratubal cyst, the presence of normal ovaries on ultrasound does not exclude the diagnosis of AT. TORSION OVARY TORSION FALLOPIAN TUBE ADNEXA Following this study, the Pediatric and Adolescent Gynecology Division completed an additional study10 to examine the postoperative course and outcome of young females treated with detorsion (DT) of torsed adnexa alone with or without cystectomy as treatment for ovarian torsion. A secondary objective was to determine which operative findings correlated with higher follicular counts following DT. 10 Santos, XM, Sokkary, N, Cass, DL, Dietrich, JE. Outcome following detorsion (DT) of torsed adnexa in children. Fertility and Sterility, Volume 96, Issue 3, Supplement, Page S92. September 2011. 59 60 P ed i atr i c and A dolescent G y necolo g y Total surgical cases 29 72.4% dusky/purple 3.4% necrotic 3.4% normal 20.7% not described Mean age at menarche 11.1 years (±0.79) Mean duration of abdominal pain on presentation 77.5 hours (±78.8) Menstrual function 100% resumed Reoperation for removal of the salvaged ovary 0% Instances of postoperative fever or concern for ovarian venous thrombosis 0% Average time of follow-up ultrasound 8.1 months (±6.7) Presence of ovarian follicles on the 28 patients (96.6%) affected side following detorsion Mean of 4.6±1.9 and 4.7±3.3 follicles for right and left ovary, respectively No correlation was found between the side affected or gross appearance of the torsed ovary and the number of follicles found on follow-up ultrasound C onclus i ons DT alone with or without cystectomy is a safe and effective treatment, and it should be considered the primary treatment for girls with ovarian torsion, even for those with ovaries that appear non-salvageable. 188 187 2010 2011 114 146 177 P ed i atr i c and A dolescent G y necolo g y O perat i n g R oom C ases by Year 237 P ed i atr i c and A dolescent G y necolo g y 2007 2008 2009 2012* * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. 4,331 4,339 145 2010 2011 587 591 4,036 158 3,368 5, 509 P ed i atr i c and A dolescent G y necolo g y C l i n i c V i s i ts by Year 2012* TEXAS CHILDREN’S HEALTH CENTERS TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. 61 62 P ed i atr i c and A dolescent G y necolo g y J enn i fer E . D i etr i c h , M . D . , M . S c . , is Chief of Pediatric and Adolescent Gynecology at Texas Children’s Hospital and Assistant Professor in the Department of Obstetrics and Gynecology and the Department of Pediatrics at Baylor College of Medicine. She is also Division Director of Pediatric and Adolescent Gynecology, the Fellowship Director for Pediatric and Adolescent Gynecology and the CME Director for the Department of Obstetrics and Gynecology at Baylor College of Medicine. She obtained her medical degree from the Medical College of Wisconsin in Milwaukee, Wisconsin and completed her residency in Obstetrics and Gynecology at Baylor College of Medicine. She went on to complete fellowship training in Pediatric and Adolescent Gynecology at the University of Louisville in Louisville, Kentucky. During her fellowship, she also obtained a Masters in Public Health and Clinical Investigation. Dr. Dietrich is currently on the editorial board of the Journal of Pediatric and Adolescent Gynecology. P ed i atr i c General S ur g er y Pediatric General Surgery The Pediatric General Surgery Division at Texas Children’s Hospital has the depth of expertise and specialization to provide optimal care across the surgical spectrum – from the most routine cases to those that are rare and complex. Each child receives personalized care from the physician most suited to the case, ensuring the best possible outcomes. 63 64 P ed i atr i c General S ur g er y The range of surgical procedures performed by the division include: • Abdominal and thoracic surgery • Fetal surgery • Minimally invasive surgery, including laparoscopic and thorascoscopic diagnosis and treatment • Oncologic surgery • Surgery to treat congenital disorders and malformations • Trauma and critical care In addition, specialized care is offered in the areas of: • Adolescent metabolic (bariatric) surgery • Anorectal malformation/colorectal disease • Chest wall deformity repair (pectus excavatum) • Endocrine and biliary surgery • Surgery to treat congenital disorders and malformations • Inflammatory bowel disease Our research programs are supported by the National Institutes of Health (NIH), Cancer Prevention Research Institute of Texas (CPRIT), private foundations, Texas Children’s Hospital and Baylor College of Medicine. Current basic research includes fetal wound healing and molecular oncology; clinical research includes cancer therapies, necrotizing enterocolitis, morbid obesity and biliary atresia. T e x as C h i ldren ’ s Hosp i tal W est C ampus The Pediatric General Surgery Division provides full coverage at Texas Children’s Hospital West Campus, including daily clinics and elective surgeries as well as extended hours for emergency procedures seven days per week. P ed i atr i c General S ur g er y M ult i d i sc i pl i nar y team The Pediatric General Surgery Division collaborates with numerous surgical divisions at Texas Children’s Hospital and supports and enhances the hospital’s medical subspecialties. Working closely with Texas Children’s Cancer Center, the division addresses the complex surgical care of children with cancer and has one of the few dedicated pediatric surgical oncology teams in the nation. As part of a surgical oncology team, specialists in the Pediatric General Surgery Division recently performed a successful procedure to remove a hepatoblastoma in an 11-week-old baby. Hepatoblastoma is an exceedingly rare malignant tumor, and only 150 cases are diagnosed in the nation each year. The tumor, which was the size of grapefruit, was removed intact with minimal damage to the patient’s liver. Doctors say the child has an excellent prognosis. T h i s y ear The opening of Texas Children’s Pavilion for Women, which has the latest innovative technology including 3D and 4D ultrasound, PET, PET/MRI and fetal echocardiograms, has expanded the Pediatric General Surgery Division’s capabilities to perform delicate in utero surgical procedures. This year, in collaboration with Texas Children’s Fetal Center, the division: • Performed the region’s first two successful in utero fetal interventions to treat severe congenital diaphragmatic hernia (CDH) with endoscopic tracheal occlusion. • Launched the first fetal interventional program in Texas to treat hypoplastic left heart syndrome (HLHS). • Completed the first successful fetal surgery to treat spina bifida at Texas Children’s Hospital. 65 66 P ed i atr i c General S ur g er y Neuroblastoma Outcomes Jed G. Nuchtern, M.D., Chief of Pediatric General Surgery and Pediatric Surgeon within Texas Children’s Cancer Center, reported the findings of a 10-year national study that found babies younger than 6 months old with small, isolated neuroblastoma tumors excel in overall progress and survival when the tumor is monitored without surgical resection. Results of the study were presented at the American Surgical Association’s annual meeting in April 2012. Eighty-three babies were followed carefully for at least 15 months. Sixteen had surgery due to staging changes. The three-year overall survival for the 83 babies was 100 percent with median follow-up now of three years. Overall, 81 percent of the babies on the observation arm were spared the need for surgery. The investigators are planning an expanded study to include patients who are 1 year old at diagnosis and have larger neuroblastoma tumors. P ed i atr i c General S ur g er y Adolescent Bariatric Surgery Outcomes The Adolescent Bariatric Surgery Program (ABSP), a component of the Pediatric General Surgery Division, has been performing the laparoscopic Roux-en-Y Gastric Bypass since 2004 to alleviate the effects of life-threatening co-morbidities associated with morbid obesity. The ABSP multidisplinary team includes a surgeon, nurse, psychologist, and dietitian and evaluates each patient for a minimal period of six months to ensure the patient’s readiness for surgery and commitment to lifestyle change. Post-surgery, patients are extensively followed and evaluated by the ABSP team to promote adherence to lifestyles changes. The outcomes of the procedure from January 2011 through August 2012 are provided below. O P E R A T I V E D A T A 11 Number of cases 20 (13 female, 7 male) Average pre-operative body mass index Average age Average length of stay12 52.7 kg/m2 16.3 years 4.3 days 30 day complications13 Reoperation-abdominal Sepsis Ateletasis Marginal ulcer Pancreatitis 4 1 1 1 1 P O S T - O P E R A T I V E D A T A 14 Number of patients Average pre-operative body mass index 52.9 kg/m2 Average body mass index (1 year post-operative) 36.2 kg/m2 Average weight lost Average percent excess weight loss 11 18 42.3 kg 62.8% Operative data from January 2011 – August 2012 One case involved a re-operation and a total length of stay of 15 days. Excluding this case, the average length of stay was 3.7 days. 12 13 Reoperation and ateletasis occurred in the same patient 14 One year postoperative follow-up occurred from January 2011 - August 2012 67 P ed i atr i c General S ur g er y Monotherapy Antibiotic Initiative for Appendicitis Over the past year, the Surgical Outcomes Center and the Pediatric General Surgery Division have worked to standardize, monitor and improve the care of our patients with appendicitis through the use of real-time data that monitors patient volumes and outcomes simultaneously. The first initiative was to improve the utilization of antibiotic monotherapy (Zosyn®) for children undergoing an appendectomy for appendicitis by 50 percent since data has shown that many of the organisms cultured at the time of surgery were resistant to the current antibiotic regimens. As of July 2012, the Surgical Outcomes Center has more than 95 percent compliance with our outcome measures and no patients have developed resistance to Zosyn. Additionally, only three patients out of the 500 treated have developed neutropenia (a potential side effect) related to its administration. * P ro j ected 2009 2010 1,012 2008 928 870 2007 840 1,250 T otal A ppendectom y P at i ents by Year 948 68 2011 2012* P ed i atr i c General S ur g er y SEPT AUG 94% OCT 95% 94% 88% 93% JUL MAY APR 2012 JUN 90% 83% 79% MAR FEB JAN 46% 90% P at i ents R ece i v i n g M onot h erap y A nt i b i ot i c b y M ont h of D i sc h ar g e in 2012 P ed i atr i c General S ur g er y O perat i n g R oom C ases 5, 567 11 432 4,785 2011 771 5,255 2010 4,823 5,330 5,637 5,969 6,609 by Year 2007 2008 2009 2012* TEXAS CHILDREN’S PAVILION FOR WOMEN TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. 69 P ed i atr i c General S ur g er y 11, 300 7,818 10,613 7,819 1,923 1,559 996 1,798 379 8,231 10,682 P ed i atr i c General S ur g er y C l i n i c V i s i ts by Year 2,072 70 2010 2011 2012* TEXAS CHILDREN’S HEALTH CENTERS TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. P ed i atr i c General S ur g er y J ed G . N uc h tern , M . D . , is Chief of Pediatric General Surgery at Texas Children’s Hospital and Professor of Surgery and Pediatrics at Baylor College of Medicine. He is also Director of the Pediatric Surgery Residency Program at Baylor College of Medicine. A graduate of Princeton University, Dr. Nuchtern received his medical degree from Harvard Medical School. He completed his General Surgery training at the University of Washington and a research fellowship at the National Institutes of Health. He received advanced training in Pediatric Surgery at Baylor College of Medicine. In addition to a clinical focus on surgical oncology and general pediatric surgery, Dr. Nuchtern conducts a basic research program that focuses on molecular target discovery in neuroblastoma, a pediatric cancer. Dr. Nuchtern is a fellow of the American Academy of Pediatrics and the American College of Surgeons. He is a member of the ACS Commission on Cancer and the Children’s Oncology Group, national consortia of pediatric oncology clinicians and research professionals. 71 72 P L A S T I C S ur g er y Plastic Surgery The Plastic Surgery Division at Texas Children’s Hospital specializes in surgical treatment of injuries or disorders that prevent children from functioning fully or looking and feeling their best. We provide comprehensive care to pediatric patients with complex surgical needs. The team includes orthodontists, with whom we collaborate on surgical treatment and orthodontia for children with congenital craniofacial anomalies and/or cleft palate. P L A S T I C S ur g er y Our highly specialized procedures include: • Aesthetic procedures, including reconstructive chest wall surgery; breast reduction; birthmark, lesion and mole removal; rhinoplasty; and otoplasty • Brachial nerve injury • Cleft lip and cleft palate repair • Craniofacial anomalies • Hand surgery and microsurgical reconstruction • Microvascular surgery for complex wounds from burns, orthopaedic injuries, amputation or replantation of extremities; nerve and muscle transplantation for facial nerve paralysis; or severe injury leading to tissue loss • Traumatic injuries, including burn scar repair, tumor excision, tissue replacement, scar tissue, deformities, skin infections and IV infiltration wounds Our innovative surgical techniques and therapy in the treatment of cleft lip and cleft palate draw patients from across the nation with deformities ranging from mildly disfiguring to extremely complex. We perform more than 400 cleft lip and cleft palate procedures each year. As leaders in the use of specialized surgeries, appliances and materials such as resorbing plates and bone-mimicking adhesives, we are able to effectively treat congenital craniofacial disorders or problems caused by injury, including facial nerve paralysis. Our use of distraction osteogenesis to correct jaw injuries or facial development issues decreases swelling and blood loss while avoiding wires, bone harvesting or blood transfusion. Dedicated to improving the lives of children through groundbreaking research, our physicians have been instrumental in several clinical landmarks, including the first use of tissue expanders to separate conjoined twins and the first parent-tochild nerve transplant. They are members of several international groups and associations, including the medical advisory board of SmileTrain®. T e x as C h i ldren ’ s Hosp i tal W est C ampus During the coming year, the Plastic Surgery Division will expand clinic, operating room and Emergency Center coverage at Texas Children’s Hospital West Campus. 73 P L A S T I C S ur g er y M ult i d i sc i pl i nar y team Drawing upon the specialized expertise of recent recruits, we collaborate with neurosurgery in the weekly multispecialty Craniofacial Clinic. Our role includes plastic surgery repair of craniosynostosis, a complex surgery that involves cranial remodeling and reshaping of bones to make the head shape more normal. T h i s y ear The Plastic Surgery Division has recently: • Begun performing orthognathic surgery, a specialized procedure to help correct the misalignment of the upper and lower jaws in certain types of cleft palate disorders. • Established a Plastic Surgery fellowship training program. • Published 20 peer-reviewed articles and continued participation in numerous research projects. Several of these have the potential to change clinical practice in areas including resorbable plates for fracture fixation, mandibular fracture fixation and craniosynostosis surgery. 2008 2009 TEXAS CHILDREN’S HOSPITAL 1,080 1,068 791 2010 12 2007 11 780 848 954 1,034 P last i c S ur g er y O perat i n g R oom C ases by Year 981 74 2011 2012* TEXAS CHILDREN’S HOSPITAL WEST CAMPUS * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. P L A S T I C S ur g er y 4,152 4,104 48 2,963 3,635 P last i c S ur g er y C l i n i c V i s i ts by Year 2010 TEXAS CHILDREN’S HOSPITAL 2011 2012* TEXAS CHILDREN’S HOSPITAL WEST CAMPUS * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. Plastic Surgery Outcomes The Plastic Surgery Division participates in the Americleft Outcomes Project, a multi-institutional project in North America involving major children’s hospitals, centered on improving speech outcomes for children with cleft lip and cleft palate. Other clinical outcome studies that are currently in progress with respect to cleft and craniofacial patients include adverse events, patient and parent satisfaction, revision rates, psychological well-being, and fistula rates. We look forward to sharing data from these initiatives in subsequent versions of our annual report. 75 76 P L A S T I C S ur g er y In memor i am The Department of Surgery is deeply saddened to share that Samuel Stal, M.D., passed away in August 2012. A renowned pediatric plastic surgeon, Dr. Stal came to Texas Children’s Hospital in 1984 following his postgraduate training in General Surgery and Otolaryngology at the University of Illinois and his Plastic Surgery residency at Baylor College of Medicine. Dr. Stal became Chief of Plastic Surgery in 1987, a position he held until his passing. Dr. Stal was one of the only surgeons in his field to dedicate his entire career to the treatment of children with cleft lip/cleft palate and other craniofacial birth defects. In addition to performing thousands of life-altering surgeries on children in the United States and recruiting top plastic surgeons and specialists to Texas Children’s Hospital, he was instrumental in bringing much-needed plastic surgery services abroad. Most recently, he traveled to Haiti where he operated for a week in very difficult conditions following the devastating earthquake. Dr. Stal’s leading surgical techniques, innovative practices and proven results earned him frequent recognition, including being named among America’s Best Plastic Surgeons, The Best Doctors in America and Houston’s Top Doctors. He was a founding member and former president of the Rhinoplasty Society, an elite group of surgeons specializing in rhinoplasty, and a founding member of the famed Dallas Rhinoplasty Course, one of the premier teaching courses of its kind in the world. L arr y H . Holl i er , J r . , M . D . , F . A . C . S . , is Interim Chief of Plastic Surgery at Texas Children’s Hospital. He is also Professor and Residency Program Director of the Department of Plastic and Reconstructive Surgery at Baylor College of Medicine. He earned his medical degree from Tulane University and completed his plastic surgery residency at the University of Texas Southwestern Medical Center, where he remained for fellowships in hand and microvascular surgery. He also completed a fellowship in craniofacial surgery at New York University Medical Center. Dr. Hollier specializes in pediatric craniofacial surgery, hand surgery, facial fractures, cranial vault remodeling, and midfacial and mandibular distraction. He has authored more than 190 articles for scholarly and professional publications as well as 37 book chapters and made dozens of presentations to professional audiences worldwide on a full range of topics related to plastic and reconstructive surgery. transplant serv i ces Transplant Services One of the most active and comprehensive pediatric transplantation programs in the nation, Transplant Services at Texas Children’s Hospital provides complex, multifaceted medical and surgical care for newborns to young adults in need of heart, kidney, liver and lung transplants. Last year, the program’s surgeons completed 83 solid organ transplantations. Our staff provides comprehensive, customized attention through all aspects of the transplant process, from initial referral to hospitalization and long-term outpatient management. Our pediatric transplant coordinators work closely with patients, families and referring physicians to ensure the evaluation process is convenient and efficient. 77 78 transplant serv i ces M ult i d i sc i pl i nar y team Transplant Services recently worked with urology, pediatric surgery and living donor teams to coordinate and perform a living-donor kidney transplant for a child with Stage 4 chronic kidney disease, as well as bilateral hydronephrosis and fulguration of the posterior urethral valve. Additionally, surgical and medical specialists in Texas Children’s Lung Transplant and the Liver Transplant Programs joined forces in a 16-hour procedure to perform a rare double-lung liver transplant to treat the effects of cystic fibrosis in a 17-year-old patient. The teen, who was diagnosed at birth with the disease, was referred to Texas Children’s, one of the few hospitals in the nation with pediatric organ transplant programs. As part of one of the nation’s top pediatric hospitals, Transplant Services offers remarkable multidisciplinary depth of care from experts in more than 40 pediatric subspecialties. We are one of the few pediatric transplant programs to have dedicated teams for anesthesia, allergy and immunology, rheumatology, pathology, pharmacy, intensive care and operating room nursing. Transplant Services worked with Texas Children’s Heart Center to complete a multi-institution clinical trial, the first of its kind, to determine the safety and effectiveness of the Berlin Heart EXCOR® Pediatric Ventricular Assist Device (VAD), the first ever VAD to provide long-term cardiovascular support for infants and children until a heart transplant is available. This trial led to the device’s FDA approval in December 2011. For more information on this groundbreaking trial, please see page 13. T HI S Y E A R Ryan W. Himes, M.D., became Medical Director of Quality and Outcomes Management for Transplant Services. Dr. Himes, a Pediatric Gastroenterologist, has clinical and research interests in defining, measuring and improving valuedelivery in health care. Flor Munoz-Rivas, M.D., an infectious disease specialist dedicated to prolonging patients’ lives through the prevention of infection following transplant, joined the Transplant Services leadership team. Dr. Munoz-Rivas also evaluates Texas Children’s patients’ immunologic status prior to transplantation. transplant serv i ces KIDNEY 25 39 23 71 32 31 27 LIVER LUNG 2010 2011 14 18 13 15 2009 13 2008 16 13 18 2007 16 11 10 14 13 17 26 51 14 11 23 70 81 83 96 T ransplantat i ons by Year 2012* HEART * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital and Baylor College of Medicine physicians at Texas Children’s Hospital surgical locations. 79 transplant serv i ces 1 Year P ed i atr i c T ransplant P at i ent S urv i val R ates 15 10 0 % 87.77% 95.26% 98.59 % 95.19 % Transplant occurred between 01/01/2009 and 6/30/2011. Pediatric Age <18 96.88 % 80 * * HEART (N=32) LIVER (N=71) TEXAS CHILDREN’S HOSPITAL LUNG (N=29) KIDNEY (N=34) SRTR EXPECTED * Per the Scientific Registry of Transplant Recipients (SRTR), there are too few events to calculate statistically powerful expected patient survival values for pediatric lung and kidney recipients. J o h n A . Gos s , M . D . , is the Medical Director of Transplant Services at Texas Children’s Hospital and Surgical Director of Liver Transplantation at Texas Children’s Hospital, St. Luke’s Episcopal Hospital and the Michael E. DeBakey Veterans Affairs Medical Center. He is also Professor of Surgery and Chief of the Division of Abdominal Transplantation at Baylor College of Medicine. He received his medical degree from Creighton University in Omaha, Nebraska and completed his residency in General Surgery at the Barnes Hospital at the Washington University School of Medicine Surgical Program. Subsequently, Dr. Goss completed a two-year multi-organ transplant fellowship in the Division of Liver and Pancreas Transplantation at the University of California School of Medicine in Los Angeles, California, where he was appointed Assistant Professor. He has been awarded the American Surgical Career Development Award, an American Liver Foundation Award and a Juvenile Diabetes Foundation Award for his efforts and leadership in transplantation. Throughout his career, Dr. Goss has performed more than 1,000 transplantation procedures. Scientific Registry of Transplant Recipients (SRTR). Program Specific Reports. Table 11 www.srtr.org 15 U R O L O GY Urology Providing surgical care for routine pediatric urological needs as well as genitourinary problems caused by congenital disorders, injury and other conditions, the Urology Division at Texas Children’s Hospital is consistently ranked among the top 10 urology programs in the nation by U.S.News & World Report. The clinically active program performs more than 2,000 operating room procedures annually, giving us comprehensive experience and skill to treat the entire range of urological conditions. In particular, our physicians have specialized focus on minimally invasive, laparoscopic surgical techniques including extremely delicate procedures in newborns and infants; anorectal malformations; urological conditions caused by neurological problems, such as spina bifida; and management of stone disease. 81 82 U R O L O GY In addition, we have particular expertise in: • Bladder extrophy and complex bladder reconstruction • Complex incontinence patients • Obstructive uropathy • Repair of genital abnormalities in males including hypospadias correction and testicular auto-transplantion • Vesicoureteral reflux and urinary tract infection Research is an integral part of the program, and our physicians are currently involved in several investigations including pyeloplasty, hypospadias and intraabdominal orchidopexy. An area of specific concentration is genitourinary development and genetics. Our physicians and fellows work closely with internationally recognized urologic researcher Dolores Lamb, Ph.D., to study the genetics of bladder extrophy, urethral valves, vesicoureteral reflux and the demographics of referral for urological care. Because urological disorders can present emotional challenges to patients and families, we work closely with child-life specialists to help ease distress and anxiety and provide long-term follow-up care for patients. Additionally, to train children with urinary incontinence to become more continent, we employ a state-of-the-art electronic biofeedback approach that helps teach children how to strengthen and control the pelvic muscles. T e x as C h i ldren ’ s Hosp i tal W est C ampus Urological surgeons at Texas Children’s Hospital West Campus provide clinic and outpatient surgery coverage as well as urodynamic services. U R O L O GY M ult i d i sc i pl i nar y team The Urology Division participates in several multidisciplinary teams and clinics including: • Anorectal Malformation Clinic: A team approach to surgical intervention for congenital deformities in which the anus and rectum do not develop properly, this clinic includes specialists from urology, pediatric general surgery and pediatric and adolescent gynecology. • Fetal Surgery Committee: Urology works with Texas Children’s Fetal Center to perform complex surgeries to correct problems including spina bifida, cloaca and other fetal anomalies. • Gender Medicine Team: This collaboration with experts from multiple divisions including endocrinology, pediatric and adolescent gynecology, genetics and psychology, addresses sexual development disorders and related ethical standards. • Spina Bifida Clinic: A team approach to surgical intervention for infants born with myelomeningocele, a congenital disorder in which the backbone and spinal canal do not close before birth. This clinic includes specialists from neurosurgery, orthopaedic surgery, urology and developmental pediatrics. • Stone Clinic: We partner with experts in nephrology and food and nutrition to address surgical, medical and dietary aspects of urinary stones (calculi). 83 84 U R O L O GY T HI S Y E A R Edmond T. Gonzales, Jr., M.D., Chief of Urology at Texas Children’s Hospital was awarded the 2012 Urology Medal for the Section on Urology by the American Academy of Pediatrics (AAP). The Urology Medal is given to an individual who has made outstanding contributions to the field of pediatric urology. Earlier this year, a laparoscopic retroperitoneal lymph node dissection (RPLND) to treat testicular cancer in a patient with horseshoe kidney, believed to be the first procedure of its kind, was performed at Texas Children’s Hospital. Horseshoe kidney, also known as renal fusion or super kidney, affects about one in 500 people. Approximately two to three men per 100,000 develop testicular cancer, creating an uncommon combination. The 16-year-old patient had metastatic disease with high embryonal and teratoma components. Since teratomas often are resistant to chemotherapy, surgery was performed ﬁrst, followed by chemotherapy at Texas Children’s Cancer Center. Before and after renderings of a patient treated for horseshoe kidney U R O L O GY 2 ,093 1,727 3 363 2,095 1,792 303 2008 2,044 1,862 2007 1,907 1,851 U rolo g y O perat i n g R oom C ases by Year 2009 2010 2011 2012* TEXAS CHILDREN’S PAVILION FOR WOMEN TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations. 85 U R O L O GY 11,213 5,943 10,809 3,092 2010 2011 2012* 2,178 2,111 3,158 265 5,540 6,907 12,395 U rolo g y C l i n i c V i s i ts by Year 5,223 86 TEXAS CHILDREN’S HEALTH CENTERS TEXAS CHILDREN’S HOSPITAL WEST CAMPUS TEXAS CHILDREN’S HOSPITAL * P ro j ected Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine faculty only. E dmond T . Gon z ales , J r . , M . D . , is Chief of Urology at Texas Children’s Hospital. He is also Professor of Urology in the Scott Department of Urology at Baylor College of Medicine, Surgical Director of Texas Children’s Hospital West Campus and holds the Edmond T. Gonzales Chair in Pediatric Urology. He is a member of the American Academy of Pediatrics, the Society for Pediatric Urology and the American Urological Association. Dr. Gonzales is boarded in Urology and was awarded a sub-board in Pediatric Urology in 2008. He completed medical school at Tulane School of Medicine and residency training in Urology at Duke University Medical Center. In 1973, he joined an active practice in pediatric urology at the Children’s Hospital of Michigan in Detroit and then came to Texas Children’s Hospital and Baylor College of Medicine in 1974. INPATIENT SERVICES Inpatient Services 87 88 INPATIENT SERVICES Acute Care Surgical Floor The acute care surgical floor, located on the 11th floor of Texas Children’s Hospital West Tower, is a 36-bed surgical care unit that admits patients of all ages from infancy to adolescents. The unit receives a wide variety of postoperative surgical patients from orthopaedics, otolaryngology, pediatric general surgery, plastic surgery and urology. We have four beds dedicated to trauma patients, and the team of nurses that cares for our trauma patient population. These beds and trained staff have been key in nearly eliminating transfer denials for trauma patients. Cardiovascular Intensive Care Unit The 21-bed Cardiovascular Intensive Care Unit (CVICU) admits newborns, infants, children and young adults with heart disease. The CVICU cares for children undergoing surgery for congenital heart disease, children and adolescents with end-stage heart failure before and after heart transplantation and children whose hearts can no longer adequately support them. Our multidisciplinary team includes cardiovascular intensivists trained in pediatric cardiology, pediatric cardiovascular anesthesiology and pediatric critical care. They work alongside our cardiac surgeons and together with a team of highly specialized nurses, respiratory therapists, nurse practitioners and physician assistants to provide the best care for our patients. Pediatric Intensive Care Unit The Pediatric Intensive Care Unit (PICU) at Texas Children’s Hospital is one of the largest pediatric intensive care units in the nation. We care for infants and children from around the globe and strive to give each child and family the best individualized care available. The 31-bed unit is staffed with critical care physicians, advanced level practitioners and postgraduate fellows all specializing exclusively in pediatric critical care. Our medical team works seamlessly with a highly skilled multidisciplinary team of PICU nurses, respiratory therapists, pharmacists, social workers and child life specialists to care for each patient. Progressive Care Unit The Progressive Care Unit (PCU) is a flexible 36-bed unit for pediatric patients who are in need of very close monitoring or complex care but do not require intensive care. Our multidisciplinary team of advanced practice providers, physician assistants, nurses and respiratory and physical therapists cares for both acute and chronic conditions. Nurses take the lead in coordinating care for patients who require continuous monitoring and observation, with special emphasis given to respiratory, neurological and surgical disorders. Many patients depend on technological support, notably those with tracheostomies. The PCU’s family-centered approach encourages parents to stay with their child and learn how to care for their child upon their return home. INPATIENT SERVICES The Cardiovascular Intensive Care and Pediatric Intensive Care Units at Texas Children’s Hospital are part of the Virtual Pediatric Intensive Care Unit (PICU) System known as VPS. This is a national pediatric critical care data registry, to which all of Texas Children’s critical care units submit data. The registry applies a predicted mortality score – PIM 2 – for every critical care admission based upon the child’s diagnosis and other indicators of illness on admission. 2011 CVICU Cases with PIM 2 Data Total cases Mortalities Mortality rate (medical and surgical patients) 872 22 2.52% Predicted mortality rate 5.6% Mortality ratio (actual/predicted) 0.45 The CVICU performed much better than predicted. The CVICU’s actual mortality rate was only 45% of the predicted rate. PICU Cases with PIM 2 Data Total cases 2,119 Mortalities 65 Mortality rate (medical and surgical patients) 3.07% Predicted mortality rate 3.70% Mortality ratio (actual/predicted) 0.83 The PICU cares for a highly complex population of both medical and surgical critically ill children. The survival rate is 96.9%. 18% of admissions to the PICU originated from the operating room or post-anesthesia care unit (PACU), and an additional 104 patients were admitted as a result of traumatic injuries. 89 90 O perat i n g R oom and P er i operat i ve S erv i ces Operating Room and Perioperative Services Designed especially for children, Operating Room (OR) and Perioperative Services at Texas Children’s Hospital provide comprehensive and specialized capabilities for surgeries ranging from routine to extremely complex. More than 24,000 procedures were completed in 30 operating rooms at five sites within Texas Children’s Hospital, Texas Children’s Hospital West Campus and Texas Children’s Pavilion for Women in 2012. From admission to recovery, our support team of more than 300 is driven to ensure an optimum experience for patients and physicians. Many of the surgical suites are fully equipped and integrated with endoscopic equipment including advanced fetascopes. Same-floor instrument processing optimizes efficiency, patient care and safety. For specialized procedures such as fetal and heart surgery, we offer customized equipment and specially trained support staff. O perat i n g R oom and P er i operat i ve S erv i ces When children are too sick to be moved to an operating or procedure room, our mobile team, which includes a fellowship-trained pediatric anesthesiologist, travels throughout the hospital to perform bedside procedures. Our commitment to children goes beyond equipment and expertise. Our strong child- and family-centered focus is one reason we consistently receive patient satisfaction rates of 92% or higher. To help ease the anxiety many children and their families feel before surgery, we offer a “virtual OR” simulator to help explain the process. In addition, details including color-coded pajamas and application of scents, such as bubble gum, to anesthesia masks help children relax and feel more at ease. To teach our surgical teams how to work together in stressful situations, build teamwork and optimize patient safety, our Simulation Center – the only one of its kind in Houston and one of the few in the nation – uses the latest technology to reproduce a realistic clinical setting. T h i s y ear We installed technology to stream live coverage of surgery between Texas Children’s Hospital West Campus and Texas Children’s Hospital operating rooms via the Internet. This interactive two-way communication allows further consultation and collaboration and has future implications for telemedicine and education. Two new programs help facilitate pre-anesthesia evaluation of surgical patients. One program focuses on high-risk pediatric patients; the other, located in the Pavilion for Women, is designed for adult obstetric and gynecological patients. The programs ensure that necessary lab tests are completed before surgery and medical history is reviewed so procedures are not delayed on the day of surgery. Pre-surgery screening helps increase OR efficiency and safety as well as postoperative pain control. 91 92 T rauma S erv i ces and t h e C enter for C h i ld h ood Injur y P revent i on Trauma Services and the Center for Childhood Injury Prevention As a crucial component of Texas Children’s Level I pediatric trauma center, Trauma Services provides around-the-clock coverage to evaluate and treat more than 1,200 injured patients each year. Teamwork is vital to the rapid and decisive actions needed to treat traumatic injuries. Our group of pediatric general surgeons and surgical subspecialists; emergency medicine physicians; anesthesiologists; child life specialists; social workers; physical, occupational and respiratory therapists; and other support staff works together effectively and efficiently when seconds matter. T rauma S erv i ces and t h e C enter for C h i ld h ood Injur y P revent i on 93 Dedicated space for trauma cases is available in the emergency center, main operating room suite and inpatient units. Approximately 70 percent of all trauma cases come from within our catchment area, which consists of nine counties covering more than 9,500 square miles. In addition, 50 percent of trauma patients seen at Texas Children’s Hospital are transferred from other hospitals, and 95 percent of these transfer requests are completed in fewer than 30 minutes. The majority are completed within 15 minutes and in one phone call. To enhance the team’s multidisciplinary performance as well as build proficiency in trauma assessment and patient care, we partner with Texas Children’s Simulation Center to conduct monthly trauma simulations. M ult i d i sc i pl i nar y team After an 18-month-old girl was attacked by a dog, causing a serious injury that destroyed the left side of her face, physicians from otolaryngology, plastic surgery, pediatric general surgery, radiology and the Department of Anesthesiology worked together to complete the complex and delicate surgical repair. 3D reconstruction of patient 3D reconstruction of patient on day of injurynearly one year later 94 T rauma S erv i ces and t h e C enter for C h i ld h ood Injur y P revent i on T HI S Y E A R When the Houston/Harris County Child Fatality Review Team, a multidisciplinary, multi-agency group to review child deaths and develop prevention strategies, was in danger of being discontinued because of budget cuts, Texas Children’s provided staff and funding to continue it uninterrupted. We are currently working to improve overall efficiency of the team and raise awareness of children’s health and safety issues. As part of our outreach and education activities, we provided trauma nursing education through the Emergency Nurses Association Trauma Nursing Core Course (TNCC), helping 147 nurses receive verification as TNCC providers, and 10 others become instructor candidates or course directors. Accidental injuries are the leading cause of death in children 14 years old and younger in the United States. To help educate parents and prevent injuries, Texas Children’s Hospital created the Center for Childhood Injury Prevention, which receives more than $500,000 in grants each year to teach parents how to keep their children safe in the car, outdoors and at home. In 2011, the Center for Childhood Injury Prevention: • Educated more than 10,000 children and parents on outdoor safety, including bicycle, pedestrian and water safety and over 12,000 people on home safety topics, including safe sleep, childproofing, and fire prevention and response • Inspected 4,318 car seats and distributed 1,682 new car seats to children in need • Provided 1,275 bicycle helmets to low-income children • Trained more than 30 child passenger safety technicians throughout the community T rauma S erv i ces and t h e C enter for C h i ld h ood Injur y P revent i on 1,242 1,254 1,250 2010 2011 2012* 615 80 0 1,041 T rauma A dm i ss i ons by Year 2007 2008 2009 * P ro j ected Trauma admissions include admissions at Texas Children’s Hospital Main Campus. T rauma A dm i ss i ons by Surgical Division 4% 2011 14% 42% 22% ORTHOPAEDICS PEDIATRIC GENERAL SURGERY NEUROSURGERY OTHER* * Other includes ophthalmology, otolaryngology, pediatric and adolescent gynecology, plastic surgery and urology. Trauma admissions include admissions at Texas Children’s Hospital Main Campus. 95 T rauma S erv i ces and t h e C enter for C h i ld h ood Injur y P revent i on T rauma A dm i ss i ons by Cause 2011 TRAMPOLINE BIKE 44 MOTOR VEHICLE CRASH 45 50 ACCIDENT 54 SPORTS 61 FALL 70 99 282 549 96 NON AUTOACCIDENTAL MOTIVE TRAUMA (CHILD ABUSE) OTHER* * Other includes traumatic incidents related to monkey bars, animals, burns, drops and more.Trauma admissions include admissions at Texas Children’s Hospital Main Campus. T rauma A dm i ss i ons by Injury Location 13% 2011 31% 6% 19% HEAD ARM LEG 31% FACE OTHER* * Other includes abdomen, chest, neck and spine. Patients may experience more than one mechanism of injury per traumatic event. Trauma admissions include admissions at Texas Children’s Hospital Main Campus. T rauma S erv i ces and t h e C enter for C h i ld h ood Injur y P revent i on T rauma A dm i ss i ons by Severity Injury Severity Scores (ISS) 2% 5% 2011 13% 80% MINOR INJURY, ISS 1-9 MODERATE INJURY, ISS 10-15 MAJOR INJURY, ISS 16-24 SEVERE INJURY, ISS ≥25 Trauma admissions include admissions at Texas Children’s Hospital Main Campus. 14% D av i d E . W esson , M . D . , is Associate Surgeon-in-Chief, Chief of the Department of Surgery and Medical Director of Trauma Services at Texas Children’s Hospital. He obtained his medical degree and completed his general surgery training at the University of Toronto and pursued his training in Pediatric Surgery at the Hospital for Sick Children in Toronto. Dr. Wesson joined the Baylor faculty as Professor and Chief of the Pediatric General Surgery Division and Chief of the Pediatric General Surgery at Texas Children’s Hospital in 1997. In 2007, Dr. Wesson was honored with appointment as the William J. Pokorny, M.D. Professor of Pediatric Surgery at Baylor College of Medicine. As a member of the American College of Surgeons (ACS) Committee on Trauma, Dr. Wesson has been an ACS Trauma Center Site Visitor since 1991. In this capacity, he is a member of the national ACS site survey team for Trauma Center designation. He also is a founding member of the International Society of Child and Adolescent Injury Prevention and serves on the editorial board of the Journal of Trauma. 97 98 MEDICAL STAFF DIRECTORY Department of Surgery at Texas Children’s Hospital D epartment of S urg ery Leaders h i p Julie Hoang, R.N., M.S., C.R.N.A. Charles D. Fraser, Jr., M.D., Surgeon-in-Chief Paul W. Hopkins, M.D. David E. Wesson, M.D., Associate Surgeon-in-Chief Matthew D. James, M.D. Thomas G. Luerssen, M.D., F.A.C.S., F.A.A.P., Chief Quality Officer Aimee Kakascik, D.O. Edmond T. Gonzales, M.D., Surgical Director, Texas Children’s Hospital West Campus Constance W. LaGrone, R.N., M.S., P.N.P. D epartment of A nesth es i olo gy Dean B. Andropoulos, M.D., Chief Cheryl R. Faust, M.P.H., Practice Administrator Melanie J. Alo, M.D. Rahul G. Baijal, M.D. Beth M. Barraza, R.N., M.S., P.N.P. Sandra L. Benavides, R.N., M.S., P.N.P. Monique Bernsten, R.N., M.S., P.N.P. Sudha A. Bidani, M.D. Glorianne Bond, R.N., M.S., P.N.P. Kenneth M. Brady, M.D. Casey A. Brimmage, R.N., M.S., C.R.N.A. Maria M. Bruno, R.N., M.S., C.R.N.A. Michelle R. Caballero, M.D. Katrin A. Campbell, M.D. Carlos J. Campos, M.D. Lisa A. Caplan, M.D. Nicholas P. Carling, M.D. Julia H. Chen, M.D. Camille M. Colomb, M.D. Erin R. Depew, R.N., M.S., C.R.N.A. Kristy D. DiMascio, R.N., M.S., C.R.N.A. R. Blaine Easley, M.D. Jessica H. Emerald, R.N., M.S., P.N.P. Christopher R. Estrada, M.D. Mary A. Felberg, M.D. Priscilla J. Garcia, M.D. Nancy L. Glass, M.D. Chris D. Glover, M.D. Cheryl A. Gore, M.D. Erin A. Gottlieb, M.D. Kalyani Govindan, M.D. Stuart R. Hall, M.D. Tekesha Henry, R.N., M.S., C.R.N.A. Lisa D. Heyden, M.D. Helena Karlberg Hippard, M.D. Javier E. Joglar, M.D. Joanna L. Klaas, R.N., M.S., C.R.N.A. Kate O. Lee, R.N., M.S., C.R.N.A. Yang Liu, M.D. David G. Mann, M.D. Virgina F. McWilliams, R.N., M.S., P.N.P. Angela M. Medellin, R.N., M.S., P.N.P. Douglas J. Miller, M.D. Wanda C. Miller-Hance, M.D. Princy Mohan, R.N., M.S., P.N.P. Emad B. Mossad, M.D. Pablo Motta, M.D. Jessica L. Mouton, R.N., M.S., C.R.N.A. Kim P. Nguyen, M.D. Olutoyin A. Olutoye, M.D. Elyse C. Parchmont, R.N., M.S., C.R.N.A. Nihar V. Patel, M.D. Mary E. Piña, R.N., M.S., C.R.N.A. Robert W. Power, M.D. Jason Reynolds, M.D. Carlos L. Rodriguez, M.D. Amber P. Rogers, M.D. Nicole M. Sevier, R.N., M.S., P.N.P. Thomas L. Shaw, M.D. Kristen D. Sheehy, R.N., M.S., C.R.N.A. Shakeel A. Siddiqui, M.D. Kristen Sowers, R.N., M.S., P.N.P. Stephen A. Stayer, M.D. Adam Stone, M.D. Imelda M. Tjia, M.D. Laura Torres, M.D. David F. Vener, M.D. Mehernoor F. Watcha, M.D. Tracy R. Watkins, R.N., M.S., P.N.P. Erin Williams, M.D. Saeed Yacouby, R.N., M.S., C.R.N.A. Jennifer G. Yborra, R.N., M.S., P.N.P. David A. Young, M.D. Michael Zelisko, M.D. MEDICAL STAFF DIRECTORY Con g en ital Heart S urg ery Shannon B. Antekeier, M.D. Charles D. Fraser, Jr., M.D., Chief Tanisha George Daugherty, PA-C Shaun E. Custard, M.H.A., M.B.A., F.A.C.H.E., Practice Administrator Howard R. Epps, M.D. Iki Adachi, M.D. Jennifer Harris, R.N., C.P.N.P.-P.C. Jeffrey S. Heinle, M.D. Amy G. Hemingway, R.N., M.S.N., C.N.S, C.P.N.P.-A.C. Vermicker L. Ible, R.N., C.P.N.P.-P.C. E. Dean McKenzie, M.D. Carlos M. Mery, M.D. Yuji Naito, M.D. (Instructor) Mary Tran, PA-C Frank T. Gerow, M.D. Darrell Hanson, M.D. Kevin S. Horowitz, M.D. Meghan M. May, M.D. Scott D. McKay, M.D. Matthew S. Miller, PA-C Scott B. Rosenfeld, M.D. Janai A. Sells, PA-C Vinitha R. Shenava, M.D. Lisa D. Stringer, PA-C Lindsey E. White, PA-C D ental Opal J. Willmon, PA-C A. Bruce Carter, D.D.S., Chief Lisa D. Wilsford, PA-C Mary D. Kana, M.B.A., Practice Administrator Vincy D. Zachariah, PA-C Bryan F. Boshart, D.D.S., M.S. Otolary n g olo gy N eurosurg ery Ellen M. Friedman, M.D., Chief Thomas G. Luerssen, M.D., F.A.C.S., F.A.A.P., Chief Jerry W. Lin, M.D., Ph.D., Chief, Hearing Center Lorraine M. Cogan, M.S.W., Practice Administrator Ryan A. Breaux, M.H.A., M.B.A., Practice Administrator Brandy Berger, R.N., N.P. Peggy Blum, Manager, Audiology Robert J. Bollo, M.D. Tina R. Bradshaw, R.N., F.N.P. James P. Carter, M.A., C.C.C.-S.L.P., Manager, Speech Language and Learning Daniel J. Curry, M.D. Linda C. Brock, P.N.P. Robert C. Dauser, M.D. Binoy M. Chandy, M.D. Andrew H. Jea, M.D., F.A.C.S., F.A.A.P., F.A.A.N.S. Carla M. Giannoni, M.D. William E. Whitehead, M.D., M.P.H. Deidre R. Larrier, M.D. O phth almolo gy David K. Coats, M.D., Chief Wendy S. Jordan, M.B.A., Practice Administrator Jane C. Edmond, M.D. Mohamed A. Hussein, M.D. Evelyn A. Paysse, M.D. Paul G. Steinkuller, M.D. Kimberly G. Yen, M.D. John K. Jones, M.D. Mary Frances Musso, D.O. Julina Ongkasuwan, M.D. Vicki L. Owczarzak, M.D. Kathy Shelly, PA-C Marcelle Sulek, M.D. Ped i atr i c and A dolescent Gy necolo gy Jennifer E. Dietrich, M.D., M.Sc., Chief Philip J. Weindorff, Practice Administrator O rth opaed i cs Jennifer L. Bercaw-Pratt, M.D. William A. Phillips, M.D., Chief Jennifer Parker Kurkowski, WHNP Binta O. Baudy, M.P.H., Practice Administrator Xiomara M. Santos, M.D. David P. Antekeier, M.D. 99 100 MEDICAL STAFF DIRECTORY Ped i atr i c General S urg ery Kidney Transplant Program Jed G. Nuchtern, M.D., Chief Christine A. O’Mahony, M.D., Surgical Director David E. Wesson, M.D., Associate Surgeon-in-Chief Lars J. Cisek, M.D. Paul K. Minifee, M.D., Clinic Chief Liver Transplant Program Cynthia F. Miley, Practice Administrator John A. Goss, M.D., Surgical Director Mary L. Brandt, M.D. Christine A. O’Mahony, M.D. Darrell L. Cass, M.D. Lung Transplant Program Bradley P. Herold, PA-C Jeffrey S. Heinle, M.D., Surgical Director Clair M. Johny, PA-C Iki Adachi, M.D. Eugene S. Kim, M.D. Charles D. Fraser, Jr., M.D. Timothy C. Lee, M.D. E. Dean McKenzie M.D. Monica E. Lopez, M.D. Mark V. Mazziotti, M.D. Allen L. Milewicz, M.D. Bindi Naik-Mathuria, M.D. Oluyinka Olutoye, M.D., Ph.D. Ashwin P. Pimpalwar, M.D. J. Ruben Rodriguez, M.D. Sanjeev A. Vasudevan, M.D. Veronica A. Victorian, PA-C Mona Jaimee Westfall, R.N., M.S.N., C.P.N.P. A.C./P.C. Plasti c S urg ery U rolo gy Edmond T. Gonzales, M.D., Chief Barkha Chandwani, Practice Administrator Lawrence J. Cisek, Jr., M.D., Ph.D. Nicolette Janzen, M.D. David R. Roth, M.D. Jessica Schuh, PA Joanna Marroquin, P.N.P. Inpati ent S erv i ces Lara S. Shekerdemian, M.D., F.R.A.C.P., F.A.A.P., M.H.A., Chief Larry H. Hollier, Jr., M.D., F.A.C.S., Interim Chief Ped i atr i c Intens i ve C are U n it Mary D. Kana, M.B.A., Practice Administrator Jeanine M. Graf, M.D., Medical Director Edward P. Buchanan, M.D. Gail Parazynski, R.N., M.S.N., Director, Nursing David Khechoyan, M.D. Laura Monson, M.D. Deborah D’Ambrosio, R.N., M.S.N., N.E.-B.C., Assistant Director John Wirthlin, D.D.S. Progressive Care Unit Transplant S erv i ces John A. Goss, M.D., Medical Director Ryan W. Himes, M.D., Medical Director of Quality and Outcomes Management Fernando Stein, M.D., Medical Director Gail Parazynski, R.N., M.S.N., Director, Nursing Jacqueline P. Williams, R.N., M.S.N., Assistant Director Jennifer J. Hiser, M.H.A., Director Cardiovascular Intensive Care Unit Heart Transplant Program Paul A. Checchia, M.D., F.C.C.M., F.A.C.C., Medical Director Jeffrey S. Heinle, M.D., Surgical Director Iki Adachi, M.D., Co-Surgical Director, Mechanical Circulatory Support E. Dean McKenzie, M.D., Co-Surgical Director, Mechanical Circulatory Support Charles D. Fraser, Jr., M.D. Carlos M. Mery, M.D. Gail Parazynski, R.N., M.S.N., Director, Nursing Gay N. Matthews, R.N., M.S.N., Assistant Director Acute Care Surgical Floor Elizabeth Brown, R.N., M.S.N., M.H.A., O.C.N., Director, Nursing Roxanne M. Vara, R.N., B.S.N., M.B.A., Assistant Director, Nursing MEDICAL STAFF DIRECTORY O perati n g Room and Te x as C h i ldren ’ s Hospital Per i operati ve S erv i ces W est C ampus Judy Swanson, R.N., M.B.A., Director, Perioperative Services Edmond T. Gonzales, M.D., Surgical Director Lynn A. Huffman, R.N., M.B.A., Assistant Director, Operating Rooms Ronald Loosle, R.N., M.B.A., Assistant Director, PACU/Anesthesia Sheila Winchester, R.N., M.B.A., Assistant Director, Perioperative Services, Texas Children’s Pavilion for Women Beth Barraza, P.N.P. Sandra Benavides, P.N.P. Monique Berntsen, P.N.P. Gloriane Bond, F.N.P. Casey Brimmage, C.R.N.A. Maria Bruno, C.R.N.A. Erin Depew, C.R.N.A. Kristy Di Mascio, C.R.N.A. Jessica Emerald, P.N.P. Tekesha Henry, C.R.N.A. Shannon McCord, M.D., Director of Patient Care Services Ramon Enad, R.N., M.B.A., Assistant Director, Perioperative Services, Texas Children’s Hospital West Campus Trauma S erv i ces David E. Wesson, M.D., Medical Director Bindi J. Naik-Mathuria, M.D., Assistant Medical Director Mary Frost, R.N., B.S.N., Assistant Director David M. Delemos, M.D. Daniel M. Rubalcava, M.D. Mona Jaimee Westfall, R.N., M.S.N., C.P.N.P. A.C./P.C. C enter for C h i ld h ood Injury Preventi on Mary Frost, R.N., B.S.N., Assistant Director Julie Hoang, C.R.N.A. S urg i cal O utcomes C enter Joanna Klass, C.R.N.A. Kathy Carberry, M.P.H., Director Constance Lagrone, P.N.P. Toni Fontenot, M.B.A., Manager, Research Kate Lee, C.R.N.A. Virginia McWilliams, F.N.P. Angela Medellin, P.N.P. Princy Mohan, P.N.P. Jessica Mouton, C.R.N.A. Elyse Parchmont, C.R.N.A. Maria Pina, C.R.N.A. Nicole Sevier, P.N.P. Kristen Sheehy, C.R.N.A. Kristen Sowers, P.N.P. Tracy Watkins, P.N.P. Saeed Yacouby, C.R.N.A. Jennifer Yborra, P.N.P. 101 6621 Fannin Street | Houston, Texas 77030 832-826-5779 surgeoninchief @ texaschildrens.org texaschildrens.org/surgery To make a referral, please visit texaschildrens.org/refer ©2012 Texas Children’s Hospital. All rights reserved.
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