Bryan L. Burke

Telemedicine: Pediatric applications

Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine’s current use bears testimony to its effectiveness and potential. Telemedicine’s widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.

Achieving Success Connecting Academic and Practicing Clinicians Through Telemedicine

OBJECTIVE. Practicing clinicians, especially in rural areas, are often isolated from learning opportunities and interactions with subspecialty providers. Pediatric Physician Learning and Collaborative Education, an interactive, educational, telemedicine program, was developed to address this need. We evaluated the success of this program through surveys with practicing and academic physicians. METHODS. Pediatric Physician Learning and Collaborative Education was assessed by using 2 evaluation forms collected from October 2007 to May 2008. One of the forms was completed by 197 attendees from the University of Arkansas for Medical Sciences and 172 attendees from remote sites. Another form was completed by 131 participants from Arkansas Childrens Hospital, an academic, freestanding, childrens hospital. Both evaluation forms asked participants to use a 5-point Likert scale to rank a number of criteria and included a section for participants to write comments and recommendations. Additional data were collected through an open-response e-mail survey of participants. RESULTS. Ninety-five percent of the participants agreed that the presentations related to their professional needs, 98% agreed that the presentations increased their subject-matter knowledge, 81% evaluated the presentations as some of the best they had attended, and 93% agreed that the information would translate into professional practice, enhancing patient care. Health care personnel from the University of Arkansas for Medical Sciences evaluated the presentations significantly higher than did remote participants. Nursing staff members evaluated the presentations significantly higher than did medical staff members. Comments were generally positive and correlated with the Likert-scale data. CONCLUSION. Participants reported being highly satisfied with Pediatric Physician Learning and Collaborative Education and considered it an effective way to address the continuing education needs of practitioners throughout Arkansas, especially in rural and underserved areas.

Rural School-Based Telehealth: How to Make It Happen

When organizing new health care interventions among a rural population, a careful planning process respecting community-specific considerations should be used. The project objective centered on the successful implementation of a school-based telehealth clinic serving a rural, health-disparate population. Using an American Academy of Pediatrics Community Access to Child Health planning grant, a needs assessment of the Delta community was conducted. In synthesizing the results of this planning project, consensually addressed issues led to establishing a pilot school-based telehealth clinic within the rural county schools. Seven essential steps emerged as a set of guidelines that entities might consider in introducing a telemedicine school-based service in a rural community. The steps included assessing local and regional needs, securing community support and establishing goals, evaluating resources, configuring logistics, training staff, informing parents, and launching the clinic. Proper planning is crucial to the establishment of a rural school-based telehealth clinic.

Smooth Implementation of Critical Congenital Heart Defect Screening in a Newborn Nursery

In January of 2012, University of Arkansas for Medical Sciences began implementation of a critical congenital heart disease screening program to identify newborns with structural heart defects. The screening used motion tolerant pulse oximeters in direct sequence to measure the oxygen levels in the right hand and either foot of eligible newborns. Exclusion criteria included echocardiogram prior to discharge, age greater than 7 days with continuous neonatal intensive care unit monitoring, or death or transfer prior to discharge. Of the 1905 infants screened, 3 infants failed screening. Two of the infants had atrial septal defects, and 1 had a patent foramen ovale, which was considered a false positive. After planning and education, the implementation of critical congenital heart disease pulse oximetry screening was successful. With only 1 false positive in our high-risk population, this should encourage other institutions to begin screening eligible infants.

Through With the Flu: How Free Family and Caregiver Immunization Protects Sick Neonates

Newborns represent the pediatric population most at risk for influenza-related morbidity and mortality, especially premature newborns and those with chronic disease. Compounding this problem is the fact that influenza immunizations are ineffective until 6 months of age. This article describes a successful program that follows the “cocoon” theory of immunization. Free influenza vaccines were given in the nursery to all family members, caregivers, and others living in the homes of discharged infants. Planning and implementation steps are described, along with lessons learned during implementation. The response to the program exceeded expectations, with 185 contacts immunized. Future plans include the expansion of the current program to include the H1N1 influenza vaccine and the Tdap vaccine. The described vaccination effort encourages and substantiates the benefits of cocoon immunization in other nurseries across the nation.

Disseminated neonatal Herpes simplex virus infection preceded by four days of prenatal maternal fever

A quick diagnosis for disseminated neonatal Herpes simplex virus (HSV) infection is not easy, potentially affecting morbidity and mortality. We report a case of disseminated HSV occurring at 4 days of life whose mother had fever for 4 days before delivery, a negative history for all sexually transmitted diseases, and a normal genitourinary examination (including visual examination of external genitalia and cervical/vaginal mucosa without colposcopy). A septic work-up done at birth was negative. A second septic work-up at 4 days of age, after clinical deterioration, led to the correct diagnosis and therapy. This case illustrates some of the difficulties in making a rapid diagnosis of neonatal HSV in all cases, especially at this age, and emphasizes the need for inclusion in this differential diagnosis and appropriate presumptive therapy.

463 CELLULAR IMMUNE RESPONSES TO VARICELLA-ZOSTER (VZ) IN THE AGED

Skin test reactivity and in-vitro lymphocyte stimulation responses to V-Z were examined in a large normal population ranging in age from 6 months to 93 years. Emphasis was on evaluation of specific immune competence of the aged. V-Z antigen was prepared from an infected culture of diploid cells. Positive V-Z skin test reactivity by age was as follows: 0-12 mo.(non-immune) 0%; 1-10 yr.-100%; 10-20 yr.-100%; 20-30 yr.-96%; 30-40 yr.-92%; 40-50 yr.-72%; 50-60 yr.-39%; and 60-100 yr.-9%. Thus, waning of cellular immunity as examined by skin delayed hypersensitivity began at age 40. Skin test responses to phytohemagglutinin (PHA) however, remained positive into the 10th decade. In-vitro lymphocyte stimulation responses to V-Z were usually positive (stimulation index ≥ 2.5) until age 60 after which time levels as observed with non-immune individuals were often demonstrated. These in-vitro results appear more sensitive in discriminating susceptibility to reactivation disease. Similar data were observed in a large group of cancer patients who, at a younger age, have depressed reactivity and likewise represent a high risk group for V-Z infection. Antibody as measured by FAMA (fluorescent antibody to membrane antigen) remained positive into the 9th and 10th decades, especially with a history of reactivation (Zoster) V-Z infection; on the other hand, skin test and in-vitro responses were rarely positive in those individuals. Thus, cellular as contrasted with humoral deficiency may account for a propensity to reactivation of varicella-zoster virus.