doctor s digest 3 Melanoma in Children: Be Aware of ABCD and Especially E 4 Physicians Join SLCH Staff

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1 doctor s digest A MONTHLY NEWSLETTER FOR ST. LOUIS CHILDREN S HOSPITAL ATTENDING AND REFERRING MEDICAL STAFFS oct/nov 2012 In this issue 3 Melanoma in Children: Be Aware of ABCD and Especially E 4 Physicians Join SLCH Staff 8 St. Louis Children s Hospital Calls for Hospitals, Clinics to Track Radiation Exposure Levels _ [faculty update] SLCH Mourns Loss of Dr. Helen Nash, First African- American physician at SLCH Helen E. Nash, MD, professor emerita (clinical) in pediatrics at Washington University School of Medicine in St. Louis, died Oct. 4, 2012, at Clermont Manor in Creve Coeur. She was 91. In 1949, Dr. Nash was the first African-American physician to join the attending staff at St. Louis Children s Hospital and the first African-American woman to join the faculty of Washington University School of Medicine. I met Helen Nash while serving as a physician in training at St. Louis Children s Hospital, said Larry J. Shapiro, MD, executive vice chancellor for medical affairs and dean of Washington University School of Medicine. I learned firsthand that she was an outstanding clinician and a great teacher. She touched the lives of her patients, their families, the students she trained and the colleagues with whom she worked. There are many physicians across the country who are grateful for her wisdom and mentorship. I am one of them. Dr. Nash served for more than 40 years on the clinical faculty of the medical school and on the attending staff of Children s Hospital. At the same time, she maintained a thriving private practice at Grand Boulevard and Cass Avenue in the African-American business district. She was heralded by physicians throughout St. Louis for her commitment to excellence, tireless advocacy on behalf of children and endless enthusiasm for the field of medicine. Helen Nash was bigger than life. She was a consummate pediatrician, a mentor to her patients and a stalwart of doing the absolute best for her patients and their families, said Alan Schwartz, MD, PhD, the Harriet B. Spoehrer Professor and chair of the Department of Pediatrics at the School of Medicine and pediatrician-in-chief at Children s Hospital. She set a high bar and spent her life helping patients exceed it. Generations of St. Louisans are all the better for Helen s presence, engagement and resolve. We miss her deeply. With her mentor, Park White, MD, Nash designed Helen Nash, MD special wards for premature infants at Homer G. Phillips Hospital and at Children s Hospital that included individual bassinets and more strict attention to hygiene and air-conditioning, according to Will Ross, associate dean for diversity and associate professor of medicine. In 1993, Dr. Nash retired from medical practice and soon began serving as the medical school s dean of minority affairs. During her tenure, she was credited with raising the academic achievements of minority students. From Dr. Nash, I learned to never compromise my principles, to elevate those around me so they might reach their fullest potential, and to always give back to the community that gave so much to her, Ross says. Her contributions to neonatology and pediatrics, public health and civil rights have made our lives and our community richer. What a life, what a legacy. The medical school recognized her lifetime contributions by creating the Dr. Helen E. Nash Academic Achievement Award, given each year to a student who exhibits outstanding qualities of perseverance, determination and enthusiasm. Born in Atlanta, Dr. Nash attended Spelman College before earning a medical degree from continued on next page Children s Direct Line StLouisChildrens.org [1]

2 Share Your Ideas Should you have ideas or suggestions you would like brought before the Children s Medical Executive Committee (CMEC), contact one of your CMEC private physician representatives: Joseph K. Goldenberg, MD David Hartenbach, MD Catherine Remus, MD Christina M. Ruby-Ziegler, MD Robert Strashun, MD Let Us Hear From You If you have comments or suggestions regarding Doctor s Digest, or if you would like to share information about your activities as a physician, contact: Amy Connelly Marketing and Communications St. Louis Children s Hospital 4901 Forest Park Avenue Suite 1022 St. Louis, MO Mailstop fax: atc7538@bjc.org Doctor s Digest Published for the attending and referring medical staffs of St. Louis Children s Hospital. Lee F. Fetter President Perry L. Schoenecker, MD Medical Staff President Joseph K. Goldenberg, MD Medical Staff President-Elect NASH continued Meharry Medical College in Nashville, Tenn., in Her father graduated from the college in She came to St. Louis to train in pediatrics at the old Homer G. Phillips Hospital, the only hospital in St. Louis offering quality specialty training to African-American physicians. There, she became chief resident. In addition to her faculty appointments at the School of Medicine, Dr. Nash also served as pediatric supervisor and associate director of pediatrics at Homer G. Phillips Hospital from 1950 to 1964 and as president of the Children s Hospital attending staff from 1977 to Dr. Nash was preceded in death by her husband, James Abernathy. She is survived by a brother, Homer Nash, MD, of Olivette; a sister, Dorothy Shack of Oakland, Calif.; nieces, Cheryl Chisholm, Terrell Mann (Steve), Karen Reynolds (Stanley), Sherry Heard, Lauren Nash Ming (Leo), Dr. Alison Nash (Clarence Dula), and Tracey Nash-Huntley (David Huntley); a nephew, Hailu Shack; friend and caregiver, Ethel Ellis; former office staff members; and a host of other relatives, friends and associates. A memorial service was held at. Oct. 27 at All Saints Episcopal Church. Visit StLouisChildrens.org/DD to read She Shattered the Color Barrier, printed in BJC Today, a BJC HealthCare employee newspaper, in Chief Resident award Each month, St. Louis Children s Hospital s Chief Residents honor a resident who shows exceptional dedication to his or her patients, colleagues or profession. In October, the SLCH Chief Resident Award was presented to Shawn O Connor, MD, a third-year pediatric resident. Dr. O Connor was recognized for almost single-handedly organizing and orchestrating an effort to inform 27 parents and primary care physicians of potential pertussis exposure in the Barnes-Jewish Hospital Special Care Nursery. He also was instrumental in arranging for droplet isolation, swabbing and administration of antibiotics to those infants. His actions showed ownership of his patients and a partnership with nurses, pharmacists, primary care physicians and other hospital staff. Together, they swiftly and efficiently enhanced the safety of a nursery filled with Shawn O Connor, MD premature and ill infants. The medical director of the Special Care Nursery, along with the nursing staff, praised Dr. O Connor s efforts and commented on how smoothly this potential disaster was averted due to his work. Perhaps Carol Scott, director of Women & Infant Services at Barnes-Jewish, summed it up best when she said, Things remained calm, hours of work were accomplished in a short period of time, and all of our babies were kept safe. [2] Children s Direct Line StLouisChildrens.org

3 [clinical focus] Melanoma in Children: Be Aware of ABCD and Especially E Symptoms of melanoma may be handily identified alphabetically: Asymmetry The shape of one half doesn t match the other half. Border The edges are irregular and often ragged, notched or blurred in outline. The pigment may spread into the surrounding skin. Color It is uneven, and shades of black, brown and tan may be present, as well as areas of white, gray, red, pink or blue. Diameter A change in size usually larger occurs. Although melanomas can be tiny, most are larger than the size of a pea (larger than 6 millimeters or about ¼ inch). Evolving The mole changes over a few weeks or months. National Cancer Institute (NCI) at the National Institutes of Health When it comes to children and teenagers, however, the E is probably the most important symptom to watch for. Melanomas in children often grow quickly, so if a pediatrician notices a new or existing mole on a patient that rapidly changes size or shape, it should be removed immediately and sent to pathology for analysis, says Susan Bayliss, MD, director of pediatric dermatology at St. Louis Children s Hospital. Because of their rapid growth, these melanomas can quickly grow deep into the skin. The deeper the lesion, the worse the prognosis because that means the cancer can get into the lymphatic channels. She adds, Physicians also need to be aware that melanomas in children often look different than those in adults. They often can be red and vascular and look similar to a wart. Although melanoma in children and teenagers is still considered rare, a 2005 study by researchers at Johns Hopkins University School of Medicine in Baltimore showed that the number of pediatric cases diagnosed each year is increasing. Using statistics from the NCI, the researchers found that between 1973 and 2001 there were 1,255 cases of melanoma in children and teens. The number of melanoma cases increased almost 3 percent every year during that time period, with the biggest increase in children aged 10 to 19. Younger children had just over a 1 percent increase in melanoma diagnoses each year. 1 We know that the younger people are when skin damage occurs from ultraviolet exposure, the higher their risk for developing melanoma. This is especially true for children with red hair and freckles or those with fair complexions who do not tan, says Dr. Bayliss. Tanning salons are definitely a factor in the increase we re seeing of teens and young adults developing melanoma. Laws imposing age restrictions for using tanning salons have been legislated by individual states like New York, Wisconsin, Illinois, Texas and Vermont, and countries including Brazil, France, Spain, Portugal, Germany and the United Kingdom. Dr. Bayliss sees this as a positive trend for a behavior she considers as dangerous as smoking. Both smoking and indoor tanning are risky behaviors that can have adverse affects on teens health in years to come, she says. Going Example of melanoma. to tanning salons can become an addictive behavior, and it is our responsibility as physicians to take as much time educating our patients about the dangers of tanning salons as we do with urging them not to start smoking. Spray tans or tanning lotions are safe alternatives that don t result in permanent skin damage. Another concern regarding melanoma for Dr. Bayliss and Brad Warner, MD, SLCH surgeon-in-chief, is the limited treatment options available for the disease. Surgery always is the first treatment for melanoma, and the prognosis for its successful removal is directly related to how thick the cancer is in the skin, says Dr. Warner. When melanomas are three-fourths of a millimeter or more deep, there s a greater chance that the cancer has spread to the lymph nodes or other parts of the body. In those cases, patients may need to undergo chemotherapy, radiation therapy, biologic therapy that uses the patient s immune system to fight the cancer, or targeted therapy using drugs or other substances to identify and attack specific cancer cells without harming normal cells. The success of each treatment is dependent upon the stage at which the melanoma is diagnosed. Currently there is no truly effective chemotherapy for treating melanoma, which makes prevention and early detection the best means of stopping this disease, says Dr. Bayliss. She notes that children with highly pigmented skin do not necessarily need sunscreen everyday because they have natural protection. But parents of at-risk children should be diligent about applying and reapplying sunscreen, buying lightweight clothes designed to block ultraviolet light, and protecting faces with wide-brimmed hats. No one, however, should be going to tanning salons for any reason, she says. Even tanning for a short time for instance, for a prom can result in skin damage that puts them at needless risk. 1 Strouse JJ, Fears TR, Tucker MA, Wayne AS. Pediatric Melanoma: Risk Factor and Survival Analysis of the Surveillance, Epidemiology and End Results Database; Journal of Clinical Oncology, vol. 23, no. 21, July 20, Children s Direct Line StLouisChildrens.org [3]

4 [faculty update] physicians join slch medical staff Anesthesiology Lynne M. Sterni, MD Assistant Professor in Pediatric Anesthesia, WUSM Specialty: Pediatric Anesthesiology Pediatric anesthesiology fellowship, St. Louis Children s Hospital Anesthesiology residency, Stanford University Medical Center, Stanford, CA Pediatric residency, SSM Cardinal Glennon Children s Medical Center, St. Louis Medical degree, University of Missouri, Columbia Cardiology Kathleen E. Simpson, MD Instructor in Pediatrics, WUSM Specialty: Pediatric Cardiology Pediatric cardiology fellowship, SLCH Pediatric residency, University of Missouri School of Medicine, Kansas City, MO Medical degree, University of Missouri School of Medicine, Kansas City, MO Cardiothoracic Surgery Umar Boston, MD Associate Professor of Surgery, WUSM Specialty: Pediatric Cardiothoracic Surgery Pediatric cardiac surgery fellowship, Stollery Children s Hospital, University of Alberta, Edmonton, Alberta, Canada Chief residency, cardiovascular/thoracic surgery, Mayo Clinic, Rochester, MN Thoracic surgery residency, Mayo Clinic, Rochester, MN Chief residency, general surgery, Mayo Clinic, Rochester, MN Cardiac surgery research fellowship, Mayo Graduate School of Medicine, Rochester, MN General surgery residency, Mayo Clinic, Rochester, MN Medical degree, Howard University College of Medicine, Washington, DC [case study] Melanoma in the Guise of a Fast-Growing Pimple Last fall, 11-year-old Autumn Vaughn asked her aunt, Kim Simmons, to look at a spot on her shoulder that was painful. There was what looked like a tiny white pimple or mole right where her bra strap hit, says Simmons. We thought it was hurting from being irritated by the strap. In February, Autumn asked her aunt to look at the spot again. It had gotten noticeably larger. It had grown so quickly, and it had turned into a pink mole that just didn t look right to me, says Simmons. Autumn had a doctor s appointment the next week, and I told her to be sure to show the pediatrician that spot. Autumn Vaughn Autumn s pediatrician sent her to a local dermatologist in Poplar Bluff, Mo., who removed the mole and had it biopsied. The result was melanoma, and the dermatologist referred Autumn to David Berk, MD, pediatric dermatologist at St. Louis Children s Hospital (SLCH). Dr. Berk had the sample retested to confirm the diagnosis, and it once again came back as melanoma. Autumn was referred to Brad Warner, MD, SLCH surgeon-in-chief, for surgery. Autumn s melanoma was fairly deep, which meant we needed to make a deep incision to ensure the margins were clear, says Dr. Warner. Imaging showed that the cancer may have spread to a lymph node under her arm, so we removed that as well. Fortunately, pathology showed the lymph node to be cancer-free. The incision was large enough to require a skin graft and resulted in additional wound issues, for which Autumn was referred to SLCH s Pediatric Acute Wound Service (PAWS). There she received advanced treatments that included IntraSite gel and Oasis temporary skin substitute derived from pig intestine. The Oasis skin substitute, which looks like a piece of tissue paper, contains live cells that basically jump start slow-healing wounds, says Jennifer Seigel, PAWS pediatric nurse practitioner. A service like PAWS is the best place for children with chronic wounds because of the specialized treatments we provide. For the next two years, Autumn will have follow-up visits every three months with her SLCH pediatric dermatologist and oncologist. And for the rest of her life, she will need to remain diligent about noticing changes in her skin, limiting her time in the sun, and always wearing sunscreen, hats, sunglasses and clothing that provide good coverage. We ve had a wonderful experience at Children s Hospital. Everyone is always so helpful and accommodating, especially when it comes to getting us in to see doctors so that we don t need to wait until the evening to drive home, says Simmons. We are just so grateful this was discovered early, and that Autumn received such excellent care. [4] Children s Direct Line StLouisChildrens.org

5 Critical Care Sirine A. Baltagi, MD Specialty: Critical Care Medical School, American University Beirut Internship, American University Beirut Internship/Residency, Cleveland Clinic Hospital, Cleveland, Ohio Fellowship, Children s Hospital of Pittsburgh, Pittsburgh, Pennsylvania Fellowship, Boston Children s Hospital, Boston, MA Stuart Friess, MD Assistant Professor of Pediatrics, WUSM Specialty: Critical Care Medical degree, Mount Sinai School of Medicine, New York, NY Internship/Residency, Mount Sinai School of Medicine, New York Fellowship, Children s Hospital of Philadelphia, Philadelphia, PA Tara Neumayr, MD Specialty: Critical Care Medicine Pediatric residency, Mayo Clinic, Rochester, MN Medical degree, University of South Dakota Jennifer L. York, MD Specialty: Critical Care Medical degree, University of Texas Southwestern, Dallas, TX Internship/Residency, WUSM Fellowship, WUSM EMERGENCY MEDICINE Charles D. Eldridge, IV, MD Specialty: Medical degree, Wayne State University School of Medicine, Detroit, MI Internship/Residency, Children s Hospital of Michigan, Detroit, MI Fellowship, WUSM Scott M. Thomas, MD Specialty: Medical degree, St. Louis University School of Medicine Internship/Residency, St. Louis University School of Medicine Fellowship, St. Louis University School of Medicine Hematology/Oncology Karen M. Gauvain, MD Assistant Professor of Pediatrics, WUSM Specialty: Hematology/Oncology Pediatric hematology/oncology fellowship, St. Louis Children s Hospital Pediatric residency, SLCH Medical degree, Saint Louis University Laura Schuettpelz, MD Specialty: Hematology/Oncology Pediatric residency, Washington University School of Medicine, St. Louis,MO Medical degree, Northwestern University, Chicago, IL Hospitalist Medicine Timothy J. Casper, MD Pediatric residency, Children s Memorial Hospital/Northwestern University, Evanston, Medical degree, Washington University School of Medicine Jennifer Harris, MD Pediatric residency, University of Nevada School of Medicine, Las Vegas, NV Medical degree, Virginia Commonwealth University Medical College of Virginia, Richmond,VA Kelsey A. Sisti, MD Pediatric residency, SLCH Medical degree, University of Arkansas for Medical Sciences, Little Rock, AR Jonathan R. Strutt, MD Pediatric residency, SLCH Medical degree, Brown University School of Medicine, Providence, RI continued on page 6 Children s Direct Line StLouisChildrens.org [5]

6 physician continued Hospitalist medicine Aline T. Tanios, MD Assistant Professor of Pediatrics, WUSM Pediatric residency, UAMS-Arkansas Children s Hospital, Little Rock, AK 2005 Pediatric Residency, St. Louis Children s Hospital, St. Louis, MO, 2006 Medical degree, Lebanese University, Faculty of Medical Sciences, Beirut, Lebanon INFECTIOUS DISEASES Michael E. Watson, Jr., MD, PhD Specialty: Infectious Diseases Medical degree, University of Missouri School of Medicine, Columbia, MO Residency, WUSM, St. Louis, MO Laboratory Medicine Ronald R. Jackups, Jr., MD, PhD Assistant Professor of Pathology and Immunology, WUSM Assistant Professor of Pediatrics, WUSM Specialty: Pathology and Immunology Medical degree, University of Illinois College of Medicine, Chicago, IL Residency, WUSM, St. Louis, MO Newborn Medicine Kathryn R. Farrell, MD Specialty: Newborn Medicine Medical degree, University of Mississippi, Jackson, MS Internship/Residency, University of Mississippi, Jackson, MS Aimee M. Moore, MD Specialty: Newborn Medicine Medical degree, WUSM, St. Louis, MO Internship/Residency, Albert Einstein College Hospital, Bronx, NY Cynthia Ortinau, MD Specialty: Neonatology Neonatology fellowship, WUSM Pediatric residency, WUSM, St. Louis, MO Medical degree,wusm, St. Louis, MO Nephrology Vikas R. Dharnidharka, MD, MPH Associate Professor of Pediatrics, WUSM Specialty: Pediatric Nephrology Pediatric nephrology fellowship, Children s Hospital Boston Pediatric residency, Children s Hospital of Michigan/Wayne State University, Detroit Pediatrics residency, University of Bombay, India Medical degree (MBBS), University of Bombay, India Neurology T. Keefe Davis, MD Specialty: Pediatric nephrology Residency, Albany Medical Center New York Medical School, St. Georges University Mike Ciliberto, MD Assistant Professor of Neurology, WUSM Specialty: Neurology Medical degree, WUSM, St. Louis, MO Internship/Residency, WUSM, St. Louis, MO Amy Licis, MD Instructor of Neurology, WUSM Specialty: Neurology Fellow, sleep medicine, neurology, WUSM, St. Louis, MO Pediatric neurology residency, SLCH Neurology residency, BJH Pediatric residency, SLCH, Medical degree, WUSM, St. Louis, MO [6] Children s Direct Line StLouisChildrens.org

7 Neurology Rafael Galindo, MD, PhD Instructor of Clinical Neurology, WUSM Specialty: Pediatric and Developmental Neurology Pediatric and developmental neurology fellowship, SLCH Neurology residency, BJH, St. Louis, MO Medical degree, University of New Mexico, Albuquerque, NM OTOLARYNGOLOGY David Leonard, MD Assistant Professor of Otolaryngology Specialty: Pediatric Otolaryngology Fellowship, Royal College of Surgeons in Ireland Fellowship, Boston Children s Hospital Residency, Royal College of Surgeons in Ireland Internship, St. Vincent s Hospital, Dublin, Ireland Medical School, University College of Dublin, Ireland Maithilee Denise Menezes, MD Assistant Professor of Otolaryngology Specialty: Pediatric Otolaryngology Fellowship, University of California-San Diego, CA Residency, University of Iowa Hospital and Clinics Residency, Virginia Mason Hospital Washington Medical School, University of Iowa College of Medicine Plastic Surgery Amy M. Moore, MD Assistant Professor of Surgery, WUSM Specialty: Plastic and Reconstructive Surgery Orthopaedic hand fellowship, Mayo Clinic, Rochester, MN Plastic and reconstructive surgery residency, WUSM, St. Louis, MO Plastic and reconstructive surgery clinical research fellowship, WUSM, St. Louis, MO General surgery residency, WUSM, St. Louis, MO Medical degree, Virginia Commonwealth U. School of Medicine, Richmond, VA Alison K. Snyder-Warwick, MD Assistant Professor of Surgery, WUSM Specialty: Pediatric Plastic and Reconstructive Surgery Pediatric plastic surgery fellowship, The Hospital for Sick Children, University of Toronto, Ontario, Canada Plastic and reconstructive surgery residency, Washington University School of Medicine/Barnes-Jewish Hospital Research fellowship, department of developmental biology and division of plastic and reconstructive surgery, WUSM General surgery residency, WUSM/BJH Medical degree, WUSM Pediatric Surgery Adam M. Vogel, MD Assistant Professor of Surgery, WUSM Specialty: Pediatric Surgery Surgical critical care fellowship, University of Texas Medical School, Houston, TX Pediatric surgery fellowship, University of Texas Medical School General surgical residency, University of Chicago, Chicago, IL Pediatric surgery research fellow, Children s Hospital Boston General surgery residency, University of Chicago, Chicago, IL Medical degree, University of Rochester, Rochester, NY Children s Direct Line StLouisChildrens.org [7]

8 One Children s Place St. Louis, MO Non-profit Organization U.S. Postage PAID St. Louis, MO Permit No. 617 Marketing and Communications Fax: In this issue _ 1 SLCH Mourns the Loss of Dr. Nash, First African-American Physician at SLCH 2 Chief Resident Award, Dr. Shawn O Connor 4 Melanoma in the Guise of a Fast-Growing Pimple St. Louis Children s Hospital calls for hospitals, clinics to track radiation exposure levels for childrens imaging tests A safe imaging measure from St. Louis Children s Hospital has been recommended for implementation nationally by a subcommittee of the National Advisory Council for Healthcare Research and Quality. The measure calls for hospitals and clinics using computed tomography (CT) systems to record the intensity of X-ray radiation exposure after each test. The exposure amount would be listed in a pediatric patient s electronic medical record. SLCH has tracked exposure data since The recommendation calls for including the SLCH measure in the Children s Health Insurance Program Reauthorization Act 2013 Core Set of Children s Health Care Quality Measures. The act includes provisions to strengthen the quality of care provided and health outcomes of children in Medicaid and the Children s Health Insurance Program (CHIP). A better understanding of X-ray use in children is needed to improve the balance between the risks and benefits of imaging, says James Duncan, MD, PhD, interventional radiologist with St. Louis Children s Hospital, associate professor of radiology at Washington University School of Medicine and chief quality and safety officer for the Mallinckrodt Institute of Radiology. Implementation of the guideline will help in linking utilization rates to facilities and patients. X-rays and CT scans expose people to ionizing radiation, high-energy radiation that can potentially damage cells and tissues. Since children s bodies are still developing, there s a higher likelihood that repeated exams can lead to too much exposure and increased risk of a future cancer. St. Louis Children s Hospital performs about 100,000 imaging exams annually, and about 6,000 of those are CT scans. A child should never be exposed to the amount of radiation we would consider appropriate for an adult patient, says Robert McKinstry, MD, PhD, Chief of Radiology, St. Louis Children s Hospital. We ensure our Dr. James Duncan authored a St. Louis Children s Hospital proposal for safe imaging that has been accepted for nationwide adoption. patients receive the lowest possible dose, in the safest environment of care. To watch a video of Dr. Duncan commenting on radiation exposure, visit StLouisChildrens.org/DD. [8] Children s Direct Line StLouisChildrens.org SLC /12