Two CHOC Children’s pediatric neurology experts will speak at an upcoming conference featuring the latest education on hydrocephalus.
Including internationally recognized medical professionals and researchers, HA Connect – National Conference on Hydrocephalus, held June 28-30 in Newport Beach, will address the medical, educational and social complexities of living with hydrocephalus through interactive discussions, workshops and hands-on exhibits. Over 500 people are expected to attend the international conference.
Dr. Michael Muhonen, board-certified neurosurgeon, division chief of neurosurgery and medical director, CHOC Neuroscience Institute, will present a lecture on the anatomy of the brain, with a focus on the cerebral ventricles, cerebral spinal fluid physiology and hydrocephalus.
On the second day of the conference, Dr. Muhonen and Dr. Anjalee Galion, board-certified pediatric neurologist and associate director of the CHOC Sleep Lab, will present on headaches and current management. Their lectures will be specifically focused on the etilogy and treatment of headaches in patients with hydrocephalus, pseudotumor cerebrii, and other brain pathology.
All CHOC professionals and employees are invited to attend. The CHOC Neuroscience Institute is offering assistance with the cost of registration. For details, email Rhonda Long, director, CHOC Neuroscience Institute at firstname.lastname@example.org.
Growing up, Tim Hicks fondly remembers seeing his dad come home from work with a smile. Despite his demanding job as physician, his dad, David, always remained positive and shared countless rewarding stories that he witnessed at the hospital.
It was that unwavering dedication that inspired Tim, now a second-year pediatric resident at CHOC Children’s and UC Irvine, to pursue a career in medicine.
“Seeing how happy my dad has been, I wanted to be part of that,” he says.
As long as he can remember, Tim was interested in medicine. He was a curious child and enjoyed science and studying about the human body.
Similarly, his dad, Dr. David Hicks, a pulmonologist and neonatologist at CHOC for more than 40 years, had always been interested in medicine as well. David wanted to become a veterinarian initially, like his father, but eventually went to medical school.
During his long and successful tenure at CHOC, David has enjoyed seeing the hospital’s growth and working alongside such a compassionate and dedicated team.
“What’s most inspiring at CHOC is the desire of our nurses and doctors to treat their patients as if they were their own. That, and when I see the smiles on the parents’ faces when their kids get better, is what inspires me to continue to do this,” says the 74-year-old physician.
It’s that same drive that motivates Tim to follow in his dad’s footsteps. His goal is to become a pediatrician, and he is also exploring a possible subspecialty.
“I really enjoy treating and hanging out with kids. They manage to smile even in a very difficult time. Their light-heartedness and innocent outlook is refreshing in many ways,” Tim says.
Tim’s relationship with CHOC goes back even further, however. His dad recalls the time when Tim, a teen then, was admitted to CHOC to be treated for a splenic fracture.
“Little did we know then that he would be back as a pediatric resident one day,” David says. “It was a few scary days in the PICU. Moments like that teach you that life is precious and things can change very quickly.”
Today, as a resident at CHOC, Tim enjoys meeting colleagues who have worked with his dad. He’s even had the privilege of meeting some of his dad’s former patients.
“We’ve definitely had fun, interesting conversations at the dinner table,” Tim says. “He’s given me great advice and taught me to treat the patient as a person; that it’s important to take care of their unique, individual needs with care and compassion.”
Tim also appreciates his dad’s outlook on the importance of a work-life balance, something he witnessed first-hand growing up. Despite his busy schedule, David always made time for things like attending his kids’ sports games, Tim remembers.
“I’ve always told my kids to find what they really love and follow that path,” David says. “And that family is very important. I owe everything to my wife, Gayle, who has taken on 50 percent of the battle, always supporting me and raising our four wonderful children.”
As Father’s Day nears, Tim – or “Hicks 2.0,” as he jokingly refers to himself – couldn’t be prouder to follow his dad’s path.
“My dad is an incredible role model and friend. I’m not only thankful for his guidance in life but also in medicine,” he says.
You open the exam room door to find an anxious mother pacing with her baby. Her son has been displaying sudden shivering moments, she says. She’s frightened that these episodes were epileptic seizures.
Indeed, watching a child shake and tremble suddenly is worrisome for any parent. But not every paroxysmal event is a seizure or neurological event.
Here are 11 such examples, and a guide to help pediatricians understand what the differential diagnosis is for seizures and other neurological events; recognize elements in the history that helps differentiate whether the paroxysmal spell is a seizure or neurological event or not; and learn what initial diagnostic workup is needed to guide management.
During these episodes, a child appears to stop breathing and may collapse, typically after a startling, frustrating or painful event. The child’s skin may be pale or purple in color, and he may show mild tonic or tonic-clonic movements. Recovery occurs in minutes. The behavior surfaces typically in children between ages 6 months and 2 years.
Though they may appear to be a seizure, these episodes are a physiological response, and not caused by electrical impulses in the brain.
Some factors to consider, however, that would call into question whether this is something other than breath-holding spells include a questionable or unclear trigger, progressively more frequent episodes, movements much more suggestive of a seizure, a very young age of onset, and a child with a developmental delay.
Children showing these red flags may require an EEG. For most, however, a workup is not typically needed, nor is treatment.
Almost all children outgrow breath holding and there is no neurological consequence.
2. Benign paroxysmal vertigo
During these episodes, a child, typically between 1 to 2 years of age, may become suddenly unsteady and fall. The child may become pale, vomit or cry, but retain consciousness. Events last minutes.
These events are considered an early migraine manifestation. Differential diagnoses include labyrinthitis, CNS tumor, epilepsy, unwitnessed head trauma and concussion, near-syncope, cardiac dysrhythmia
More worrisome are events that are unremitting and not episodic; include a loss of consciousness; show other neurological signs such as seizures, weakness or hearing loss; or are experienced by a child with a developmental delay can be more worrisome.
Workup for children exhibiting these events could include a brain MRI, ENT evaluation or EEG.
These episodes are typically not progressive or degenerative, but do indicate a likelihood for migraines in teen and adult years.
3. Shuddering attacks
Patients experiencing these events have shivering moments that last seconds, which can occur sporadically or multiple times a day. They occur most typically in infants ages 6 to 15 months, and they do not lose consciousness.
These events are behavioral, and differential diagnoses include seizure or tics.
Longer episodes; rhythmic twitching; a change of awareness or consciousness; and color change are red flags, as is an event experienced by a child with developmental delay or abnormal exam.
A video captured at home is often sufficient for diagnosis, and no workup is needed. No treatment is necessary for these events, and a child’s prognosis is excellent.
4. Infant gratification
This is a normal phenomenon, more commonly known as masturbation, that can include dystonic posturing, grunting, rocking, eidetic imagery and sweating. Typically experienced by children 2 months to 5 years of age, these events can occur sporadically or multiple times a day.
Children’s skin may change color and they may seem tired afterward. The event can be stopped in progress, but a child may get upset if the parents stop the behavior.
Red flags for this behavior include unresponsiveness, tonic-clonic movements or cyanosis, and a differential diagnosis is partial seizures.
A video captured at home is often sufficient for diagnosis, and no workup is needed. Treatment is behavioral based, and prognosis is excellent.
5. Staring spells
These episodes occur in children of any age, but are common in children with autism. The spells may look like day dreaming or inattention, but are often redirectable.
Often, the events are behavioral or related to frontal lobe processing. Differential diagnoses include absence or complex partial seizures. Episodes wherein children are not redirectable, show a change in coloring or behavior, or have a cognitive decline are more worrisome.
Workups include EEG, ADHD evaluation, neuropsychological evaluation for learning disabilities and cognitive abilities, or a psychological evaluation.
Treatment can include psychology or behavioral therapy, neuropsychology and appropriate educational setting, or stimulant medication as needed.
In general, a child’s prognosis is typically excellent. Children with ADHD have a generally good prognosis, but may have variable response to treatment with stimulant medications. A prognosis for those with learning disabilities depends on the severity, classroom setting and educational factors.
Shown in younger infants from birth to age 6 months, these events look like twisting and writhing movements that aren’t typically sudden. However, patients may show some sudden flexion and extension of the body, arms or legs. Children’s skin may redden.
Children exhibiting these events may have low muscle tone that contributes to relaxed muscle at esophageal-gastric junction.
Differential diagnoses include seizures, infantile spasms or movement disorders, and red flags include no association with feeding, stereotyped movements like jack-knifing or sudden flexion in clusters, or cyanosis.
Workup includes clinical diagnosis, further investigation following a finding of low tone on exam, sometimes upper GI or other GI studies, EEG or video-EEG monitoring.
Treatment includes H2 blockers or proton pump inhibitors.
Patients’ prognoses are generally excellent with symptoms resolving over time. However, for children with significant GI pathology or neuromuscular conditions, the prognosis is guarded.
7. Tics/Tourette’s syndrome
These episodes include the twitching of one muscle or a group of muscles, but rarely involve larger muscle groups. Though repetitive, they are not typically rhythmic or prolonged. They do not cause falling, and do not typically restrict activities.
They can occur in a variety of ages, and older children may describe a feeling that they must make the movement. Vocal tics include grunting, humming, clicking and sniffling, but rarely formed words.
As pathophysiology, structural and functional neuroimaging studies have shown the involvement of the basal ganglia and related cortico-striato-thalamo-cortical circuits, and the dopaminergic neuronal system.
Differential diagnoses include myoclonic seizures. A change of consciousness, inability to suppress, onset in sleep, and episodes that are rhythmic and repetitive are red flags.
Workup includes a clinical diagnosis, EEG or screening for the presence of ADHD, OCD or other behavioral disorders.
Most children do not need treatment for tics, unless the behavior is disturbing physically or socially. Central alpha agonist medications (Clonodine, Tenex) or dopamine antagonist drugs (Haldol, Risperdal, ORAP, Pimozide) can be useful.
Most children outgrow tics, and up to 15 percent of people diagnosed with Tourette’s outgrow the condition.
Typically shown in early childhood after age 1, these episodes are marked by repetitive stereotyped movements that may or may not be rhythmic. They are self-stimulatory and otherwise without purpose. Examples include hand flapping or rocking. Events may persist into adulthood, especially in patients with autism or an intellectual disability.
These events are behavioral in nature, but a differential diagnosis is automatisms with complex seizures.
Red flags include a change in awareness, which can be difficult to detect in children with autism, and events that are rhythmic and repetitive.
Workup includes and EEG, and treatment is applied behavior analysis or therapy from a psychologist. For children who can be taught not to exhibit the behavior, prognosis is good.
9. Night terrors
These episodes are more common in children around age 3, but can surface earlier and persist into teenaged years and adulthood.
A patient may awake from deep sleep with a terrified look, screaming and showing decreased responsiveness. They may tremble, and episodes may occur several times a night.
Their exact mechanism is unknown, but night terrors may be genetic.
Differential diagnoses include nightmare, seizure, arousal disorder or parasomnia. Episodes are more worrisome if they occur many times a night, include strange repetitive movements like pelvic thrusting or bicycle pedaling motions, or are accompanied by progressive academic or developmental decline.
Workup includes a history and clinical diagnosis, polysomnogram or video EEG sometimes combined with polysomnogram.
Most children grow out of night terrors and do not require treatment, but can benefit from counseling on sleep habits or psychology. Though rarely, medications like clonazepam or amitriptyline can be helpful.
These events are more common in teenaged patients. They include a sudden and brief loss of consciousness typically with associated loss of muscle tone. Patients may fall or slump forward or backward, and have mild twitching. They might also have a light-headed, giddy feeling or blackening of vision.
Loss of consciousness lasts only seconds, and patients may hear people around them before vision returns. They may feel groggy afterward, but not confused.
Recovery is quick, and episodes typically have a trigger: standing up too quickly, standing in place too long with legs locked, dehydration on a hot day, emotional fright, valsalva including defecation or urination, hair traction, or venipuncture.
These episodes are not a primary neurological event, and a common feature is reduced cerebral perfusions. They stimulate the vagus nerve, which causes bradycardia. Decreased venous tone allows venous pooling and decreased blood return to the heart. Valsalva prevents venous return to heart
Differential diagnoses are complex partial or other types of seizures, or postural orthostatic tachycardia syndrome.
Red flags include no provoking factor, prolonged and prominent tonic-clonic movements or hemi-clonic movements, cyanosis, or occurrence in very young children or those with a neurological or developmental disorder.
Workup includes diagnosis based on clinical history; orthostatic blood pressures; EEG if any red flags are present; and KG/Holter study, tilt-table testing, or cardiology consult if the patient’s clinical history is suggestive of dysrhythmia.
Treatment includes counseling on how to avoid symptoms, including standing up slowly, drinking water and avoiding triggers.
Looking forward, a predisposition to fainting may continue into adulthood. The episodes don’t cause neurologic injury, but a patient could get injured from a fall.
11. Cyclic vomiting
These episodes entail one to five days of copious vomiting, followed by asymptomatic periods. The average age of patients is 5, but episodes can span from infancy to adulthood.
They usually start in early morning or late afternoon. Abdominal pain, anorexia, lethargy, pallor, sweating and salivation accompany the episodes.
Triggers include emotional stress, energy-depleting states, some foods and menstrual cycles.
To diagnose, the patient must have stereotypic episodes of vomiting with at least two acute-onset episodes in the past six months, each occurring at least one week apart and persisting for less than one week.
Red flags include periods of unresponsiveness, tonic-clonic movements, visual changes, other neurological symptoms such as hemiparesis, hematemesis and melena.
Workup includes MRI or GI referral and endoscopy.
IV fluids, anti-nausea medication, pain relief medication is common treatment. Periactin; amitriptyline; antiepileptic medications with migraine indications (Depakote, Topamax, others); and propranolol can be used as prophylactics.
Long before Dr. Carlos Konishi was a seasoned pediatric psychologist at CHOC Children’s, he understood firsthand the healing effects of flower therapy.
As a psychology intern at CHOC more than a decade ago, he would create flower arrangements for the psychology department in his spare time, and quickly noticed the positive impact it had on the wellness of patients and his colleagues.
Inspired largely by his Japanese heritage, known for its deep appreciation of nature, Dr. Konishi had always enjoyed working with flowers and plants as a pastime, and even used it as a therapy technique with patients in another facility.
As part of his dissertation, Dr. Konishi studied the possible impact of nature settings on people’s physical and emotional health.
“Our appreciation for nature is cross-cultural. At a very basic level, we are drawn to nature and how it makes us feel,” Dr. Konishi explains. “Think of a favorite vacation spot for instance; you often think of a place tied to nature. There’s something about nature that makes us feel reconnected and refreshed.”
In 2016, Dr. Konishi returned to CHOC to work as a full-time psychologist, and he continues to use the art of flower arranging today to encourage mindfulness and wellness among his colleagues. Every Monday, he sets up a flower therapy station in his department’s break room, including a variety of fresh flowers and colorful vases, which his fellow colleagues and students can use to create arrangements for their individual offices and therapy rooms where patients are seen.
The physical act of arranging the flowers and concentrating on the soothing task stimulates mindfulness, Dr. Konishi explains. Like with other mindfulness activities, the task allows you to focus on the present moment and acknowledge your feelings, thoughts and sensations.
He also enjoys creating flower arrangements for the hallways in the office like he once did as a student. He and his team often hear from patients and their families who comment on these beautiful touches of nature and how uplifting it makes them feel when they come in for an appointment.
“It’s part of your emotional health. When you see things that are aesthetically pleasing, you feel good,” Dr. Konishi says. “Flowers are a representation of the beauty of nature.”
Dr. Konishi’s commitment to his mental and emotional health and that of his colleagues does not stop with flower therapy, however. He and a few colleagues have formed a wellness committee in their department. Throughout the year, they organize activities such as Smoothie Day, pet therapy, yoga and flower arranging with the goal to help staff reset and be more present for their patients’ care. The committee has also organized Tea for the Soul through CHOC Spiritual Care as well as Healing Touch therapy and Reiki sessions for the department staff.
“Wellness and mindfulness programs can be beneficial for everyone and can play a very important role in decreasing burnout and increasing engagement,” Dr. Konishi says. “I strongly recommend creating a small team of individuals who share an interest in wellness to ensure sustainability and allow for a variety of activities. These activities don’t have to be very long and can provide a reprieve from the daily stressors people face and can help them recharge and refocus throughout the week.”
As our current fiscal year comes to an end, I am pleased with all the progress we have made this year and look forward to new and exciting information technology (IT) projects on the horizon. Last February, we welcomed a new vice president and chief information officer, John Henderson, to our organization. He joined us from Texas Children’s Hospital and has been a huge addition to our leadership at CHOC Children’s. A seasoned IT leader, John has a successful track record of guiding cohesive teams in the design, deployment, administration and enhancement of enterprise IT applications and infrastructures. We are also excited to onboard our new chief technology officer, Adam Gold, who will also be a great addition to our team. The CTO is a new position for CHOC and Adam will be responsible for all our infrastructure including computers, networks, data center, communications and other technologies.
Currently, our technical staff just finished the roll-out of tap-and-go access to our clinical computers in the inpatient areas, emergency department, surgery (outside of OR and procedure rooms) and Outpatient Infusion Center. Now, when you log-in to our systems from these clinical areas, you can tap-in with your badge. This has been a huge win, especially for our nursing staff, saving them a lot of time during the day as they frequently log in and log out. We hope to continue to optimize the performance of this technology and implement it in our clinics and other outpatient service areas beginning in July.
Remote access to our systems is also changing with the addition of two-factor authentication (2FA), a security process in which the user provides authentication factors to verify they are who they say they are. This is just as essential for protecting patient medical records as it is your bank account. While 2FA is not new, it has become more prevalent in the current digital age. Beginning in June, we will be cancelling access to remote.choc.org for those who have already registered for two-factor authentication and over the following months, we will be switching all remote users to secure.choc.org. Stay tuned for more information coming soon.
We are currently implementing a new Dynamic Documentation build in our Children’s Medical Group (CMG), replacing their current PowerNotes documentation. Beginning in July, we will be implementing our Cerner EMR in our other primary care practices, along with Cerner Pro Fee billing, and a new version of Cerner’s registration and scheduling called Cerner Practice Management (CPM). CMG and our specialty care clinics that are part of CHOC Children’s Network will also be going to the new Pro Fee billing and CPM over the next year. These enhancements are a huge undertaking, which are currently consuming our IT resources and may delay some of the requests that are frequently submitted. We ask for your patience over these next several months.
In addition, we are continuing to advance our work in population health, data science and analytics. We are also continuing to develop new technologies to improve the care of our patients with chronic diseases, advance home monitoring technologies, better support our care management staff both in and out of the hospital, and develop predictive models for readmission and patient deterioration, among other things.
Lastly, we are eagerly awaiting the final word on our capital budget for FY19 to determine what new projects are approved for next year. Our highest priority right now is to implement E-prescribing for controlled substances (EPCS), which we hope to do in the first half of FY19.
Should you have any questions about any of these developments, or other issues related to current information technology systems, please feel free to contact me at email@example.com, or at 714-509-7637.