Mark Bittles, M.D., outlines the medical mystery of a 15-year-old girl with a history of deep vein thrombosis that doctors thought they had addressed with a stent in the iliac vein in the girl’s abdomen. The girl, who carries the diagnosis of May-Thurner Syndrome, had returned to the Emergency Center with pain in the lower left part of her abdomen. But why?
As Bittles, an interventional radiologist at Johns Hopkins All Children’s Hospital, presents the case, questions and comments come from clinicians in a variety of disciplines in a hospital conference room and from those around the country watching the Multicenter Pediatric Thrombosis & Stroke Case Conference on the internet. Bittles describes how he adapted “fluoroscopic” X-ray images to create a full lateral view of the abdomen, which shows that the stent had malfunctioned and become twisted, despite the stent appearing normal on the usual frontal X-ray.
“It is important to understand the limits of what we’re looking at,” Bittles says of the initial set of images captured before he rotated the camera.
Bittles believes he corrected the girl’s problem with a procedure he hadn’t used since his fellowship a decade ago, placing a stent within a stent. The malfunctioning stent was a novel development for most of those viewing the presentation.
Consulting and Teaching
Exploring cases such as the one Bittles presented with colleagues around the country is exactly what Neil Goldenberg, M.D., Ph.D., the director of research at Johns Hopkins All Children’s, had in mind when he started the conference using web-enabled, video conferencing in 2012.
Goldenberg, director of the thrombosis program in the hospital’s Cancer & Blood Disorders Institute as well as director of the stroke program in the Institute for Brain Protection Sciences, encourages attending physicians, trainees and advance practice providers in pediatric hematology, neurology, neuroradiology and interventional radiology to participate. Some cases also draw interest from other specialties, such as cardiology, vascular surgery or neurosurgery.
“In pediatrics, the relatively low incidence of many potentially devastating diseases means that any one hospital or academic health center is very challenged to bring optimal subspecialized expertise and experience to the care of such children who present with challenging diagnostic and treatment scenarios,” says Goldenberg, also a professor of pediatrics and medicine in the division of hematology in the Johns Hopkins University School of Medicine. “Pediatric hospitals are also challenged to provide optimal training in complex cases of rare diseases for their residents and fellows, who represent the next generation of pediatric experts. Given the broad availability and low cost of videoconference technology, I hope that this example of ‘virtual’ case-conferencing will serve as a model for improving value and outcomes for pediatric patients who have other rare and potentially life-threatening or life-altering health conditions.”
In another recent case conference, Ryan Felling, M.D., Ph.D., a Hopkins assistant professor in child neurology who directs the pediatric stroke program at The Johns Hopkins Hospital in Baltimore, Maryland, presented the case of a teenager with an acute severe stroke who received urgent treatment with clot-busting therapy, thanks to a pediatric stroke alert system and clinical care pathway for acute stroke in children.
Many cases presented at the monthly conferences are from the Johns Hopkins Medicine campuses in St. Petersburg and Baltimore; however, presentations often are made from other institutions. Doctors mask protected health information when they summarize patient history and physical exam findings and review key laboratory test results and imaging studies.
Physician experts in hematology, neurology, and/or interventional radiology from The Johns Hopkins Hospital in Baltimore along with hospitals in Orlando, Florida, Kansas City, Missouri, and Billings, Montana, were among those who listened in and commented on Bittles’ presentation. Centers from Atlanta; Cincinnati; Denver/Aurora, Colorado; Houston; Kalispell, Montana; New Orleans; New York; and Portland, Oregon, have contributed to past conferences.
“We get a different group each month,” says Marisol Betensky, M.D, M.P.H., a Hopkins assistant professor of pediatrics who, like Goldenberg, is a St. Petersburg-based expert in thrombosis and stroke. “Physicians and trainees from centers all over the country join us to deliberate on challenging pediatric cases from which we all can learn, and from which we hope the patients benefit from having multiple experts weighing in.”
The case conference is embraced at Johns Hopkins All Children’s since strokes and blood clots affect so many disciplines.
“The stroke and thrombosis case conference allows Johns Hopkins All Children’s to bring together specialist physicians from multiple disciplines locally and from around the nation to review these rare cases for the benefit of children here and elsewhere,” says George Jallo, M.D., medical director of the Institute for Brain Protection Sciences. “It is an excellent tool for collaboration and teaching.”
Peter Shaw, M.D., deputy director of the Cancer & Blood Disorders Institute, agreed: “Our goal has been to leverage Dr. Goldenberg’s internationally-recognized expertise and extensive experience, along with that of his colleagues at Hopkins and around the nation, to increase value and improve outcomes for children with thrombosis and stroke not just at Hopkins, but around the country ... and we’ve been succeeding in this goal.”
A Valuable Tool
Bittles attends the conference regularly and has presented cases several times. For him, the collaboration is key.
“The case conference is an efficient way to share our group’s skill set with others, and to learn from our colleagues around the country in order to better treat patients with uncommon conditions,” he says. “Individual patients receive immediate and long-term benefits as we grow our fund of knowledge.”
Visit HopkinsAllChildrens.org/Stroke and HopkinsAllChildrens.org/Thrombosis to learn more about the stroke and thrombosis programs at Johns Hopkins All Children’s.