WINTER 2015 Newsletter Children’s Vol 1 Issue 1 Specialty Group PulmonologySpo light on Vocal Cord Dysfunction (VCD) by Jose “Frank” Chocano, MD Both and vocal cord dysfunction (VCD) can make breathing di cult. Signs and symptoms of either condition can include dyspnea, coughing, noisy breathing (stridor or wheezing), throat or chest tightness and hoarseness. Some children with asthma also develop VCD. Vocal cord dysfunction is the abnormal and in- Services voluntary paradoxical closing of the Our practice provides evaluation, di- during inspiration. As with asthma, exposure to agnosis, management and treatment of airway irritants, an upper respiratory viral infec- diseases aecting the lungs in patients tion, gastro esophageal reux (GERD) or exer- from birth through 21 years of age. cising may trigger VCD. Although asthma and e most common conditions VCD may have similar triggers and symptoms, the we treat include the following: treatment approach for VCD is very dierent than asthma, recurrent cough or wheeze, treatments used to manage and control asthma. cystic brosis, bronchopulmonary is makes proper diagnosis essential. dysplasia, chronic lung disease, bron- chiectasis, respiratory insu ciency, You may suspect VCD rather than asthma if: congenital malformations of the lung, pulmonary hemosiderosis, pulmonary • During ares your patient complains that it’s hypertension, immotile cilia disease, harder to breathe in than breathe out spine and chest wall disorders, sleep • Asthma medications don’t seem to ease the disorders and dyspnea with exercise. symptoms • Results of routine breathing (pulmonary func- Referrals to Pulmonology tion) tests for asthma are normal Please provide us with a reason why the patient is being referred to our practice. • Your patient’s symptoms are not due to a respi- ratory infection alone, something in his/her air- Normal vocal-cord abduction We also ask that you provide a list of (Top) and Severe vocal-cord ab- current medications and medication ways or another health problem duction (Bottom) during inhala- delivery devices as well as any relevant Diagnosing VCD can be challenging! is may tion. e paradoxical movement doctor’s notes, labs, and chest X-rays clearly illustrates the “diamond- that may not be accessed through lead to further tests such as with in- shaped posterior chink.” CHKD’s EHR. spiratory and expiratory ow volume loops, an ex- ercise challenge or the direct observation of vocal cord closure during (continued on next page) HIS ISSUE IN T

2 The Inside Scoop 3 Hats-Off 6 CF Newborn Screens 8 Dreams Do Come True CSG Leadership notes Special Awards Cynthia Epstein, MD Urgent Care for Kids

2 Spacer or Nebulizer 4 Places & New Faces 7 Cough in Children 8 MaRxs of Distinction Shana Crabtree, MD Division contact info Marilyn Gowen, MD Why CSG is so Special (Fold-out) Bridges: Winter 2015 Newsletter Volume 1 Issue 1 3

(cont’d) inspiration using a laryngoscope. Treatment for VCD typically involves activities that relax the throat muscles, speech therapy and deep breathing techniques. A Pulmonologist has specialized training and experience in the diagnosis, treatment and management of conditions such as asthma and VCD. to a Job Welcome to our first edition of BRIDGES! Our journey together begins.... Dr. Chocano joined CSG in 2005. He Did You Know? Well Done! I’m sure you are wondering, “why another is boarded in Pediatric Pulmonology and Sleep Medicine. When he’s not Harbor View is now open! newsletter?” providing excellent patient care, 5838 Harbour View Blvd Frank loves spending time with his family. Suffolk, VA 23435 Recently, I was asked to chair the He also enjoys watching professional soccer Patient appointments available in: marketing committee for CSG. At the and listening to the classic-rock stylings of his Allergy, Cardiology, Dermatology, Developmental Pediatrics, Gastroenterology, time, I felt like nothing in my skill set son Elliot...but not at the same time! Nephrology and . suggested that I was trained to help Resident Team Players market a practice, but I knew what Helping House Staff Dr.’s Jennifer Simmons Supporting a Great Cause grabbed me and what I would look for , was recently Dr. Bryan Greenfield Why choose a Spacer over a Peter Farrell , Nic Rister Dr. Shana Crabtree and expect from a medical practice. Reeti Kumar and for providing Spanish by Shana Crabtree, MD for working extra honored at the Brewer’s Ball: interpretation in the PICU Nebulizer? unscheduled hours in the ED by A Celebration of Hampton Roads’ Since I joined Children’s Specialty Group coming down from floor duties after midnight for a Spanish (CSG), CHKD, and EVMS fourteen years Wheezing-related illnesses are a common reason for physician visits. Some Finest young professionals. She was speaking family during children may benet from and inhaled . It is to help see patients in the given the Horizon award for raising ago, I have often worried about the ED during a particularly busy for Virginia Chapter downtime when the interpreter disconnect between the medical school, up to the physician to choose the method of delivery and educate the family. A over $10,000 phone was not available. spacer with or without a mask is an excellent option for aerosol delivery at home, overnight shift. of the Foundation. the hospital and the physicians. I am the o ce, the emergency room and the hospital as evidence-based literature has reminded of this gap each time I think demonstrated. of my beloved friend, Dr. Don Lewis, who Multiple studies have demonstrated that albuterol can be delivered eectively via somehow was able to juggle the interests spacer. Castro-Rodriguez et al J Pediatr 2004 found six prospective randomized of each entity and kept everyone focused Great Community Teaching Attention to Detail control trials looking at albuterol delivery in the emergency department. Dr. Kent Reifschneider on what pulls us together. Meta-analysis demonstrated a decreased admission rate in moderate to severe Community Education Dr.’s Joel Brenner, David Smith, , as Chair exacerbations and improved clinical symptoms in children under 5 years of age. for recently giving and Aisha Joyce , from Sports of the Nutrition committee at CHKD, When I was asked to create a newsletter ese studies did demonstrate a wide range of four to ten pus of albuterol MDI Dr. Peter Dozier Medicine, continue to provide has worked diligently to provide for CSG, I knew I wanted it to be something to be equivalent to 2.5mg nebulized albuterol. e wide range is due to many a half day symposium at Chesapeake education to physical therapists, nutritional menus in the cafeteria that could bridge the gaps in perception, factors including the type of holding chamber and the delivery technique. A Bay Academy for the community athletic trainers, coaches, parents and inpatient setting. He also created knowledge, and communication among valved anti-static holding chamber has the highest deposition of particles. on effective behavior modification and other health care professionals in and instituted educational videos and in children with ADHD. He was also our community. They address concerns posters on how to properly measure those groups. In these times of global Regarding inhaled corticosteroids, there are no studies directly comparing the installed on the school’s Board of infants and children. Literature threats, ever-changing standards of care, delivery of budesonide via nebulizer to uticasone via meter dose inhaler. In including concussions, sports related Directors to help establish and injuries and performance enhancing indicates 70% error rate in clinics. and a multitude of health care access randomized control trials, uticasone has been demonstrated to be safe and maintain policies that provide an e cacious in preschool children (Qaqundah et al J Pediatr 2006); and uticasone substances in an effort to keep Posters available for all pediatric and utilization issues, a small newsletter optimal education for children with has improved pulmonary function and symptoms in infants with recurrent behavioral challenges. Hampton Roads athletes safe and offices. may not have world impact. However, wheeze (Mallol et al Allergol Immunopathol 2009). healthy. They have provided over we hope to provide some educational 28 community lectures in information as we highlight different Based on the above studies, spacer use has been demon- the last 12 months. subspecialties, improve patient access by strated to be safe and e cacious in infants for both bronchodilators and inhaled corticosteroids. A providing resources, phone numbers and spacer is also more e cient, convenient, faster tips, and inform you of new research, and less expensive. e neb- ulizer uses milli- projects, equipment and new faces that grams, while the MDI uses micrograms; yet equal amounts of appropri- ate size particles are part of CSG. e nebulizer is less portable than the spacer, requires electricity and is more reach the lungs. A nebuliz- er takes approxi- Dr. Shana Crabtree completed The ultimate goal is to improve the mately 10 minutes per treatment, while di cult to clean. e spacer can be cleaned with soap and water. Regarding medical school at the University of communication among our healthcare the spacer treat- ment can occur in total costs, the nebulizer is more expensive. However, insurance companies Louisville, pediatric residency at the two to three minutes. oen cover the nebulizer and require higher co-pays for spacer and MDIs. University of Virginia and fellowship community so we can all continue to at Texas Children’s Hospital. Shana joined enhance the lives of our patients, one Our CHKD pulmonology practice recommends spacer with MDI in CSG in 2013. Her interests include asthma, Bridge at a time. appropriate patients of all ages for the reasons indicated above. It would cystic brosis, be our pleasure to work with you and your patients to provide them with and lung transplants. She also has strong and teach them appropriate spacer technique. Our practice follows Chest interests in nutrition and exercise. When Angela Hogan, MD guidelines which include shaking inhaler, good seal with or without mask, she’s not tending to her patients’ needs, Dr. pu, breathe slowly in and hold for 10 seconds or six breaths if using a Crabtree can likely be found in the company Editor-in-Chief, CSG Bridges of “Orrie,” her 110-lb blue merle Great Dane! Children’s Allergy, Asthma, and mask, followed by one minute between pus. Immunology Bridges: Winter 2015 Newsletter Volume 1 Issue 1 5

ADOLESCENT MEDICINE NEONATAL-PERINATAL MEDICINE Main: 757-668-8786 757-668-8000 Fax: 757-668-7855 CSG Places & New Faces Fax: 757-668-9345

ALLERGY / IMMUNOLOGY NEPHROLOGY Main: 757-668-8255 Lauren Smith, MD Rachel Armentrout, MD Main: 757-668-7244 Fax: 757-668-9444 Allergy/Immunology Neonatal-Perinatal Med. Fax: 757-668-9814 “My current hobbies include ‘lacta- “My interests include hiking, ANESTHESIOLOGY tion consultant’ to my young son, international travel (most recently NEUROLOGY Main: 757-668-7320 playing omas the Tank Engine, to Rome) and nally living in the Main: 757-668-9939 Fax: 757-668-9735 and telling my Newfoundland pup- same city as my husband.” Fax: 757-668-9905 py that he can’t take things o of the dining room table.” CARDIOLOGY OTOLARYNGOLOGY Main: 757-668-7213 Main: 757-668-8272 Fax: 757-668-8225 Dayna Perkowski, MD Fax: 757-668-9838 Neurology CHILD & FAMILY GUIDANCE PATHOLOGY “My hobby (and fallback career) is Main: 757-668-8869 creating professional-quality cakes Main: 757-668-7275 Fax: 757-668-8870 for my sons’ birthdays; at least Fax: 757-668-9175 Children’s Specialty Group that engineering degree wasn’t a CRITICAL CARE MEDICINE complete waste!” PHYSICAL MEDICINE & REHAB Main: 757-668-8000 Main: 757-668-9153 Fax: 757-668-9345 Fax: 757-668-9925 DERMATOLOGY Ayanna Butler-Cephas, MD Rosemarie Santos, MD PSYCHOLOGY Main: 757-668-7857 Main: 757-668-9757 Fax: 757-668-8795 Endocrinology Hospital Med. / Emergency Med. Fax: 757-668-8288 “I enjoy playing with my 3 year “In 2014, aer 11 years together, I old daughter and working out. I’m DEVELOPMENTAL PEDIATRICS married my med-school sweetheart. PULMONOLOGY excited about living in Virginia I love cooking, traveling and Main: 757-668-6484 and having my second child here spending time with my family.” Main: 757-668-7426 Fax: 757-668-7474 in March 2015.” Fax: 757-668-7784

EMERGENCY MEDICINE RHEUMATOLOGY Main: 757-668-8000 Main: 757-668-8572 Fax: 757-668-9345 Many CSG Divisions routinely see new patients within 2 Fax: 757-668-7784 weeks of referral, however all will work with you to get ENDOCRINOLOGY GENETICS urgent patients in. For referral information please HOSPITAL MEDICINE SLEEP MEDICINE Main: 757-668-7655 Main: 757-668-9723 go to the desired specialty at: Main: 757-668-8000 Main: 757-668-7902 Fax: 757-668-8215 Fax: 757-668-9724 www.csgdocs.com/specialties Fax: 757-668-9345 Fax: 757-668-7198 Click on the “Referral Information” link. GASTROENTEROLOGY HEMATOLOGY / ONCOLOGY There you will find information that will help INFECTIOUS DISEASE SPORTS MEDICINE Main: 757-668-7240 Main: 757-668-7185 facilitate a successful referral for your patient. Main: 757-668-7238 Main: 757-668-8786 Fax: 757-668-7721 Fax: 757-668-7811 Fax: 757-668-8275 Fax: 757-668-7885 Bridges: Winter 2015 Newsletter Volume 1 Issue 1 7

Newborn Screening in CF by Cynthia Epstein, MD Cough in Children: When Does it Matter? Cystic Fibrosis (CF) need further evaluation. ere are a few patients that by Marilyn Gowen, MD newborn screening began will have two mutations found on newborn screening in Virginia in March but have a negative sweat chloride test. ese patients Cough is a common complaint for patients visiting the pediatrician. e chronic cough can be especially annoying 2006. e importance need to be followed by the CF Center. in the pediatric population. A chronic cough is dened as a cough of >4-8 weeks duration. e causes of chronic of newborn screening cough can be subdivided into specic and nonspecic and, unlike with adult cough, the relationship between for CF has been well For those determined to be carriers, a discussion asthma, upper airway disorders, GERD and cough is not well proven in children. established. ere have regarding the carrier state with the families is necessary. been several convincing ese children will not be symptomatic, but being a e management of chronic cough should be based on the specic etiology, and if possible, treating the underlying studies recently including carrier may impact future reproductive issues. It is disorder should treat the cough. OTC cough medications are to be avoided. also important to make the parents aware that either two randomized control Children with chronic cough should be evaluated for specic signs and symptoms pointing toward an underlying trials, ve cohort studies, one of the parents is a carrier or they both are carriers. erefore, carrier screening is recommended for both disease (such as failure to thrive or clubbing with cystic brosis). In some children, the quality of cough may be and data from the two helpful, as with a brassy cough suggesting tracheomalacia. Any associated exacerbating factors should also be registries in the United parents if they are planning on future children. In addition, the parent or parents determined to be the evaluated. Children with a history of a chronic cough should undergo a CXR and spirometry (if 4-6 years+). Photo credit: March of Dimes States and UK. e carrier may want to inform their families with regard to If spirometry shows reversible , the child should be treated for asthma. However, evidence studies looked at growth shows that in most children isolated cough does not represent asthma. If the child does not improve with asthma and nutrition, survival, healthcare utilization, lung their carrier status because their family members are at risk for being carriers as well. therapy, the CXR is abnormal or spirometry does not show reversible airway obstruction, consider input from a function, pulmonary score, and cognition. e data is pediatric pulmonologist for possible aspiration, recurrent , interstitial lung disease, airway anomaly or overwhelmingly supportive for improved care and better ose patients with one mutation and a sweat chloride other less common pulmonary condition. long-term outcomes the sooner CF can be diagnosed. test of 30-59 mmol/liter have several diagnostic Newborn screening prevents early malnutrition possibilities. ey could be a carrier, have actual If, on the other hand, both the CXR and spirometry are normal and the cough is nonspecic, watch and wait and vitamin deciency, reduces early pulmonary CF or could have CRMS or CFTR (Cystic Fibrosis for several weeks as the cough is likely post-viral. Review again the possibilities of foreign body aspiration, complications, and decreases multiple co-morbidities Transmembrane Regulator Protein) Related Metabolic medication eect (ACE inhibitors), pertussis, GERD, tobacco smoke exposure and functional disorders (habit, that occur with delayed diagnosis. Syndrome. ese patients require a repeat sweat tic, psychogenic). Evaluate the child’s activity and the parental expectations, and reevaluate the child in 2 weeks. chloride test by 2 months of age. If that test is still 30-59 If the cough continues with no specic sign pointing to underlying disease, consider another 2 weeks of watching Newborn screening for CF involves the testing of IRT and waiting versus a trial of therapy. erapy for a dry cough would be a 2-3 week trial of 400ug/day budesonide or Immunoreactive Trypsinogen. Trypsinogen is one of mmol/liter, then further genetic testing is required along with a repeat sweat chloride test at 6 months of age. If (ICS) equivalent, and a wet cough would be a 10 day course of antibiotics, both with reevaluation in about 2 the major components secreted by the human pancreas weeks. If there is no improvement from either trial, referral to a pediatric pulmonologist would be suggested. If and is also measurable in the bloodstream. Increased the infant has one mutation and a sweat chloride test of less than 40 mmol/liter with no clinical symptoms of the budesonide works, consider using it only for a limited time period if there are no other signs of asthma. If the blood IRT in CF is likely secondary to blocked ductile antibiotics work but the recurs, consider further investigation. secretions in the pancreas. In December 2011, the CF, they are a carrier and no further testing is required. Commonwealth of Virginia changed their previous If the sweat test is between 40-59 and they have one CF Treatment of nonspecic cough includes parental education and addressing their concerns and expectations method of screening with 2 IRT to a two tier test mutation or they have two CF mutations and a sweat test regarding their child’s chronic cough. is will be more helpful than any nonspecic treatment. A single report approach. First, an IRT is measured from the newborn of less than 60, they have the diagnosis of CRMS. CRMS showed cessation of parental smoking improved cough in children but there have been no randomized control screening card. If the IRT is abnormal, further DNA is dened by having a positive IRT along with the sweat trials. OTC cough medications oer little if any benet to the control of pediatric cough and testing is performed looking for 39 genetic mutations chloride testing and genetic testing results as described. the AAP has advised against the use of codeine and dextromethorphan for treating any and four polymorphisms that are present in children Consensus guidelines were published in 2009 by e cough, both because of lack of eect and risk of signicant morbidity. ere is no evidence with CF. If a positive IRT was found with zero mutations, Cystic Fibrosis Foundation [J Pediatr. 2009 Dec;155 to support the use of ICS, anticholinergic agents or bronchodilators in children with this is a “false positive” and no further testing is required (6 Suppl): S106-16. doi: 10.1016/j.jpeds.2009.09.003]. cough with no evidence of airow obstruction. A recent Cochrane review showed if there is no clinical suspicion of CF. Samples with an Although the long-term prognosis is felt to be excellent that antibiotics did not help cough due to acute URIs but, with proven , elevated IRT and one or two identied CFTR mutations for patients with CFTR Related Metabolic Syndrome, a 10-day course reduces the probability of the persistence of cough. While are considered “screen positive”. Some patients need to these patients should be followed by a CF Center. antihistamines with or without decongestants help those >15 years of age, they have sweat chloride testing done. Special situations you have minimal if any eect in children. No benecial eect of GERD therapy has would want to do sweat chloride testing include: Dr. Epstein received her medical degree from SUNY Buf- been shown on cough in children. While cough is a common complaint, getting to falo and performed her Pediatrics residency at MCV. the bottom of it can be very benecial for families dealing with this life disruptor. • Screen positive patients with two mutations Since the completion of her fellowship at Baylor Uni- • Screening positive with one mutation versity, Cynthia has practiced Pediatric Pulmonologic medicine for over 13 years. She joined CSG’s Pulmonology Dr. Gowen is a graduate of the CSG • All babies with meconium ilieus Division in 2005 where she has also served as the CHKD Cystic University of Richmond and CARES! • Newborn screen negative and develop clinical signs or Fibrosis Center Director for 9 years. She enjoys photography, ani- received her medical degree from symptoms of CF mated movies, and traveling with her husband and 6 year old son. Virginia Commonwealth University. That’s why, in 2014, we She did her Pediatrics residency at e gave over $150,000 to GIVING Optimal sweat chloride results are obtained aer 2-3 University of Louisville and her fellowship charities that share and weeks of age. Both arms are used for the test in order training in Pediatric Allergy, Immunology CHKD Did You Know? and Pulmonology at Duke University. She support our mission: BACK to get at least one result that has su cient sweat. If the Education, Research, sweat chloride test is less than 30 mmol/liter and there Children’s Specialty Group has was an attending at East Carolina University St. Mary’s is no clinical suspicion for CF, then the child is a carrier for ve years before joining CSG, CHKD & Patient Care for EVMS Home for and no further testing is required at that time. If the one of three statewide specialty and EVMS in 1990, where she is now the Children! EDMARC Disabled sweat chloride test is 60 mmol/liter or higher, then this is CF centers with more than Division Director of Pediatric Pulmonology. Children consistent with the diagnosis of CF. If the sweat chloride 400 patient visits per year. test is between 30-59 mmol/liter, then the child will CHKD recently key services closer to opened a new Urgent Care Centers families. With urgent Pediatric Urgent care, however, we Care Center. is worked together to center is located Answer Community Need! build a new service in Chesapeake at 817 Volvo by Angela Hogan, MD from the ground up. It was very Parkway and is the region’s rst exciting and rewarding to be a part urgent care center exclusively for of that. Guins says response to the infants, children and teens. “As new service has also been gratifying. the newest member of our CHKD “On our rst day, parents pulled into Health System, CHKD urgent care the parking lot 10 minutes before we expands our ability to provide age- opened and it’s been like that every appropriate care to the children of day since,” she says. “Parents are our region when and where they asking me why we didn’t do this years need it,” says CHKD President ago!” and CEO, Jim Dahling. e urgent been part of the CHKD emergency care center oers care for common department for 20 years, but it was Dr. Guins said the center is in no way pediatric illnesses and sports her experience as a mother that meant to replace the pediatrician or injuries and is open nights and convinced her of the community’s family practitioner, but to improve weekends, when most pediatric need for a pediatric urgent care. communication between urgent care practices are closed. and primary care providers, in part “About 10 years ago, as I sat with through shared electronic health eresa Guins, MD, the other moms in a playgroup records. e clinic hours are 4-11 a board-certied and talked about our children’s p.m. during the week and 11 a.m. pediatrician and pediatric pediatricians and my job as a to 11 p.m. on weekends /holidays. emergency medicine Pediatric Emergency Medicine e new location also has pediatric specialist with CSG, Specialist in the CHKD ED, I X-ray technicians and lab specialists. serves as medical director of the o en heard the statement, ‘I wish e new location also has pediatric new service and worked closely CHKD was closer, I won’t drive x-ray technicians and lab special- with CHKD Vice-Presidents into Norfolk unless my child is ists. e new urgent care center may John Hamilton and John Harding really sick!’ In the decade since not be as convenient as the old-fash- and urgent care administrative then,” she continues, “CHKD has ioned house call, but it’s close to it. director, Angela Robertson, to overcome that concern by building If you need more information, go to open the center. Dr. Guins has Health Centers that bring many CHKD.org/UrgentCare.

CSG’s Mission is to: Provide High Quality Care and Excellent Service; Provide Efficient, cost competitive healthcare; Promote Medical Education and Research; Enhance relationships with healthcare providers and delivery systems.

Ma CSG is comprised of over 150 Pediatric Specialists along with more than 20 Advanced Practice Providers practicing in 27 Pediatric of Specialties!

Distinction CSG’s Neonatologists, Hospitalists and Pediatricians provide neonatal care at 8 area hospitals 24/7 – 365 days per year.

In 2014, CSG Specialists provided over 130,000 outpatient patient care visits.

CSG’s Emergency Medicine Specialists and Pediatricians saw over 50,000 children in the CHKD Emergency Room last year. Do you have an idea for the next newsletter? Email: CSG supports the Patient Center Medical Home Model of Care by [email protected] supporting our community-based pediatric colleagues!