In the Spotlight: Jonathan Minor, M.D.

The newest addition to the CHOC Children’s Orthopaedic Institute team, Dr. Jonathan Minor brings a unique expertise in ultrasound-guided injections and procedures, as well as diagnostic ultrasound evaluations. As a non-surgical sports medicine physician, he has a special interest in sports and dance injuries, concussion management and advanced musculoskeletal ultrasound medicine.

CHOC Children's Orthopaedic Institute

Dr. Minor’s commitment to helping young athletes stems from his own experience growing up playing sports. As an adult, he has completed multiple marathons and Ironman triathlons, including three Long Course World Championship races with Team USA.

In addition to recognizing and treating acute injuries, Dr. Minor is dedicated to preventing overuse injuries. His research has been diverse: identifying running gait mechanics related to injuries, reporting of concussions, and evidence-based approaches to joint injections. He presented original work at the 2015 American Academy of Pediatrics National Conference showing concussion reporting among high school football players remains problematic, and is trying to shed light on risk factors that may influence reporting.

Dr. Minor’s passion for sports medicine and orthopaedics was inspired by his father, an accomplished orthopaedic surgeon.

“I was moved by my dad being able to take an injury, and just like a carpenter, put it back together,” Dr. Minor said. “As a non-surgeon, I consider myself more like an architect, laying out a floor plan, and bringing together a team of providers to safely return our athletes back to the sports arena. I recognize that often there are multiple ways to solve the same problem.”

Dr. Minor attended medical school at Texas A&M University System
Health Sciences Center, College of Medicine. He completed his residency training at McLane Children’s Hospital Scott & White, followed by a non-surgical sports medicine fellowship and an additional musculoskeletal ultrasound fellowship at Boston Children’s Hospital.

During his training in Boston, he served as team physician for several collegiate and high school teams, including Northeastern University men’s and women’s basketball and soccer teams.  He also worked closely with the Boston Ballet.

Dr. Jonathan Minor

A chance to work with the expert team at CHOC eventually led him back to his native California. He was drawn to the opportunity to help grow the program. The CHOC Orthopaedic Institute plans to expand the footprint of the sports medicine program, with the addition of physical therapists, new regional physical therapy locations, and integrating injury prevention with clinical practice. The department has also added Dr. Jessica McMichael, an orthopaedic surgeon, who will help to develop an osteogenesis imperfecta program at CHOC.

Dr. Minor has quickly become an integral part of the team, treating everything from ankle and knee ligament sprains, to overuse injuries and concussions. Through the use of ultrasound-guided injections, he provides bedside visualization of body tissues, which can confirm the location of pain and assist with surgical decision-making. Classically, injections are performed blindly, with risk of poor accuracy, or with fluoroscopy, with exposure to radiation and often, increased discomfort. The ultrasound-guided injections offer a quicker recovery and can sometimes be used to avoid surgery altogether.

“While cortisone injections are not performed brazenly among pediatric patients, they can be used judiciously here at CHOC to provide cutting-edge care,” Dr. Minor explains.

He offers physicians the following guidelines on when to refer:

  • An acute injury or ankle sprain, with negative x-rays and pain after 1-2 weeks.
  • Persistence of pain despite rest, ice, compression/bracing, stretching and physical therapy.
  • Persistent joint swelling.
  • Painful popping and clicking.

Dr. Minor sees patients at CHOC Children’s Clinic; CHOC Children’s Health Center, Corona; and Adult & Pediatric Orthopaedic Specialists in Mission Viejo. To contact him, please call 949-600-8800, ext. 205.

 

When Vascular Anomalies Are More Than a Blemish

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Dr. Daniel Jaffurs (center), surrounded by his colleagues in surgical services, with the latest pulsed dye laser model – the Vbeam Perfecta.

Many babies are born with small blemishes—a little patch of redness here, a birthmark there. While these typically aren’t cause for concern, some cases may become problematic and require extra care.

“If a hemangioma is in a cosmetically sensitive area, or if it’s impairing vision, eating or hearing, it should be referred to a specialist,” according to CHOC Children’s plastic surgeon Daniel Jaffurs, MD. “A rapid-growing or large hemangioma should also be referred.”

Casey’s Story

 When Casey Lang was born, she had two small marks on her body: one on her left cheek, and one on her abdomen. Doctors initially diagnosed it as a stork bite that would go away on its own. By the time Casey was two months old, however, the blemish on her face had become blotchy and was encroaching on her eye, and the growth on her abdomen had grown to the size of a lime.
Casey at birth and at two months old.
Casey at birth and at two months old.

Casey’s parents took her to her pediatrician, who referred her to Dr. Jaffurs. Immediately upon seeing Casey, he diagnosed the marks as infantile hemangiomas and consulted with the rest of the team from the CHOC Children’s Vascular Anomalies Center. They recommended that Casey be admitted to CHOC that day for comprehensive testing, to determine the severity of the hemangiomas.

“They started her on propranolol in the hospital and the journey started from there,” mom Michelle says. “It was a year on the medication, and we came to CHOC every single month. The medication was remarkable. It brought down the hemangioma on her face and opened up her eye.”

The growth on Casey’s stomach did not respond as well to the medication and was surgically removed by Dr. Jaffurs. What remained of the hemangioma on Casey’s face, however, could be treated with a simple procedure that had just become available at CHOC.

No Surgery, No Scar

CHOC’s new pulsed dye laser (PDL) is a minimally invasive treatment for hemangiomas, port-wine stains and post-surgical scarring anywhere on the body. The laser delivers very quick pulses of energy at a specific wavelength that is absorbed into the skin, destroying the abnormal blood vessels just below the surface. CHOC uses the latest PDL model—the Vbeam Perfecta— because of its level of precision, which is especially important when lasering sensitive areas like near the eye.

Casey after her first laser treatment, and after her second laser treatment.
Casey after her first laser treatment, and after her second treatment.

“With this new laser, we sometimes can avoid an operation which leaves a lasting scar,” Dr. Jaffurs says. “And, you can see the results immediately.”

CHOC’s pediatrics-trained anesthesiologists give patients a small amount of anesthesia using a mask, to relax them and minimize movement during the procedure. Patients are sent home the same day; side effects are very minimal and may include slight pain or bruising. The number of treatments needed depends on the location and size of the vascular anomaly.

Casey was one of the first patients at CHOC to be treated with the pulsed dye laser and after just two treatments, the hemangioma on her face is nearly gone. Most patients require three to five treatments depending on the severity of the malformation.

“I want other parents to know that if their child has this, there is a cure for them,” Michelle says. “The team they have at CHOC, it’s just amazing, and if you go there, you’re going to get answers.”

The CHOC Children’s Vascular Anomalies Center brings together pediatric specialists in hematology, plastic surgery, head and neck surgery (ENT), dermatology, cardiology and more to assess and treat all forms of vascular anomalies and malformations in children. For more information, call 714-509-3313.

 

CHOC Children’s Grand Rounds Video: Cognitive Side to Mental Health and the Psychology Behind Concussions

A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive and psychiatric symptoms, Drs. Sharief Taraman and Jonathan Romain said in a recent grand rounds presentation at CHOC Children’s.

Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.

The doctors explain that cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion.  Psychiatric symptoms often include irritability, liability and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contribute to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.

Learn more about CHOC’s Concussion Program.

View previous grand rounds videos.

Impact of Precision Medicine on Oncology Field

Precision medicine is changing how physicians think about treatments, with great advances coming out of the oncology field.  In podcast No. 42, three CHOC experts and speakers at the upcoming Peds2040 conference, Dr. Anthony Chang, Dr. Leonard Sender and Spyro Mousses, Ph.D., discuss exciting developments impacting patients today and offering tremendous hope for the future.

Dr. Sender, medical director of the Hyundai Cancer Institute at CHOC, is determined to find a cure for cancer and prevent or reduce the toxicity associated with treatments.  Under his leadership, CHOC has programs in place that bring together big data, bioinformatics and genomic sequencing.  In addition to discussing what CHOC is currently doing, he and Dr. Mousses, whose interested include artificial intelligence, share plans for the near future, including offering very complex molecular profiles in collaboration with multiple specialists and institutions, including hospitals and bioinformatics companies from across the nation.

To hear more from these three thought leaders, listen to episode No. 42:

CHOC Radio theme music by Pat Jacobs.

Stroke in Pediatric Patients: Occurrence, Intervention and Beyond

By Dr. Sharief Taraman

Many might picture a stroke patient as middle aged or elderly, but

Dr. Sharief Taraman, CHOC Children's pediatric neurologist
Dr. Sharief Taraman, CHOC Children’s pediatric neurologist

the reality is that the ailment occurs across the lifespan.

A stroke affects one in every 3,500 live births and six to 13 per 100,000 children per year.  At CHOC Children’s, that translates to one or two patients per month outside the newborn period.

Among many risk factors, the largest for stroke in children include cardiac disease (19 percent); coagulation disorders (14 percent); and dehydration (11 percent). Multiple risk factors are present in up to 25 percent of pediatric stroke patients.

Atherosclerosis and modifiable risk factors that dominate adult stroke mechanism and treatment were nearly non-existent in pediatric stroke. However, in the past decade and a half, traditional cardiovascular risk factors for stroke in people ages 15 to 34 have been steadily increasing.

Placental diseases can cause perinatal arterial stroke, and perinatal stroke accounts for a large proportion of pediatric stroke morbidity. The first week of life carries the most risk for stroke and the majority of survivors have lifelong morbidity, most typically, hemiparetic cerebral palsy. Cognitive or behavioral disorders and epilepsy are also common.

Acute ischemic stroke (AIS) lesions are often multifocal, even in the absence of overt cardiac disease, which lends support to proximal embolic source. Many neonates with AIS have risk factors and presentations that overlap with hypoxic ischemic encephalopathy, and the two can co-occur.

Delayed diagnosis

Despite these occurrences and the inherent dangers, a lack of awareness prevails and diagnosis of childhood stroke is often significantly delayed. One study found up to a 28-hour delay in seeking medical attention from the onset of symptoms and a 7.2 hour delay after presentation before any brain imaging occurred (Lenn, et al, 2002).

Further complicating matters is that presentation can be subtle, varied and non-specific, and often occurs in the setting of a systemic illness. One study found the median time to diagnose AIS in neonates was 87.9 hours and 24.8 hours in children (Mackay, et al 2009). Another study saw that 19 of 45 children with a stroke did not receive a correct diagnosis until 15 hours after initial presentation, and in some cases, up to three months afterward (DeVeber, et all 2006).

Also, many other diseases mimic a stroke: A fifth of children presenting for evaluation of suspected acute stroke have a “stroke mimic,” rather than an actual stroke (Shelhaas, Pediatrics, 2006). Stroke mimics include migraines and delirium, as well as seizure and tumor.

Intervention

High-powered clinical trials that guide adult stroke management – including antiplatelet and anticoagulant strategies; chemical and mechanical thrombolysis; stroke unit care; and many others – do not yet exist for children.

Of 687 children enrolled in the International Pediatric Stroke Study (2011), 15 patients received tissue plasminogen activator (tPA): nine underwent intravenous tPA and six underwent intra-arterial tPA. The median time to treatment from onset was 3.3 hours for intravenous alteplase and 4.5 hours for intra-arterial alteplase.

Of those patients, four had intracranial hemorrhage (non-symptomatic); one died from brainstem stroke; one died from massive stroke with herniation; one was discharged without deficits; and 12 were discharged with neurological deficits.

Intravenous tissue plasminogen activator (tPA) needs more study for safety, dosing and efficacy before it can be fully applied to pediatric patients. Dosing in children cannot be extrapolated from adult data or existing pediatric data.

Limited pediatric safety and effectiveness data also exists around neurointerventional techniques like intra-arterial tPA and mechanical thromboectomy. Early intervention results in better outcomes, though success rates depend heavily on the operator’s experience.

Rehabilitation, recurrence

Similar to the adult stroke population, rehabilitation is multifaceted and comprises neuropsychology; developmental monitoring; educational intervention; and physical, occupational, and speech therapies. Most of the functional recovery occurs in the first two to three months. The quality of functional recovery is better in the pediatric population; however, the prognosis worsens as the lesion size increases.

The risk of recurrence following a stroke is up to 25 percent and highest in the first three months of onset. The lowest risk of recurrence is in perinatal and cryptogenic stroke.

Like any other condition, prevention of pediatric stroke is important and many patients will be placed on antiplatelet or anticoagulation. Interestingly, children with some, few or no vaccinations are shown to be at risk of stroke seven times higher than those who received all or most vaccinations.

CHOC has a collaborative team with protocols in place to recognize and treat pediatric stroke aggressively. Learn more about the CHOC Children’s Neuroscience Institute.