Fall 2010 - SSM Cardinal Glennon Children's Medical Center

SSM Cardinal Glennon Children’s Medical Center
Fall 2010
www.cardinalglennon.com
FOCUS ON
Pediatrics
®
MEDICAL NEWS FROM SSM CARDINAL GLENNON CHILDREN’S MEDICAL CENTER AND
THE DEPARTMENT OF PEDIATRIC SURGERY, SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE

ON THE COVER
“I will not cut persons laboring under the stone,
but will leave this to be done by men who are
practitioners of this work.” – Hippocrates
Anand V. Palagiri, M.D., performs laser lithotripsy on Irhad Sehovic, 15, to
remove a large, painful kidney stone. Dr. Palagiri passed a small caliber scope into
Irhad’s urinary tract to reach the painful stone. It was successfully fragmented and
removed with the use of a laser fiber.
Knowledge of stone prevention and treatment has come a long way since
the era of Hippocrates, especially in terms of pediatric stone disease.
In addition to laser lithotripsy, SSM Cardinal Glennon’s Pediatric Stone Center
offers patients an all-inclusive approach to treating urinary stone disease with the
latest technological treatment advances.
FOCUS ON Pediatrics
®
Editor In Chief
Sherlyn Hailstone
President
Medical Editor
Kenneth Haller, MD
Associate Professor of Pediatrics
Editor
Andrew Sutton
Physician Services Manager
Writer & Designer
Katelyn Ideus
Physician Communications Specialist
SSM Cardinal Glennon
Children’s Medical Center
Saint Louis University
School of Medicine
SSM Cardinal Glennon
Children’s Medical Center
SSM Cardinal Glennon
Children’s Medical Center
For comments and suggestions, please email FocusOnPeds@ssmhc.com.

Announcements
SSM Cardinal Glennon Welcomes Faculty
Jerry
Rosenblum, M.D.
Gastroenterology
The Division of Gastroenterology at
SSM Cardinal Glennon Children’s
Medical Center is pleased to announce
the addition of Jerry Rosenblum, M.D.,
to its team of four gastroenterologists.
Dr. Rosenblum joins Cardinal Glennon
after 18 years in private practice and
30 years of experience. He continues
to see patients at St. Luke’s Hospital in
Chesterfield, Mo., as well as St. Joseph
Medical Park in St. Charles, Mo.
Stephen
Braddock, M.D.
Director, Medical Genetics
This fall, Cardinal Glennon’s Division
of Medical Genetics welcomed Stephen
Braddock, M.D., as Division Director.
Dr. Braddock joins Glennon after serving
as Professor of Clinical Pediatrics
at the University of Virginia School of
Medicine.
Awards
William Keenan, M.D.
American Academy of Pediatrics,
“Virginia Apgar Award.”
Recognizing Dr. Keenan as a
pioneer in the field of neonatal
resuscitation and as one of the
founding members of the Neonatal
Resuscitation Program.
AAP National Conference &
Exhibition; San Francisco, Calif.
October 2, 2010.
Thomas Foy, M.D.
Shalini Paruthi, M.D.
Ellen Wood, M.D.
SSM Cardinal Glennon’s
2010 St. Luke’s Faithful Healer.
Recognizing physicians for
dedication to our values of
compassion, excellence, stewardship,
community and respect.
Presentations
Alexander
Lin, M.D.
Director, Plastic Surgery
Christina
Plikaitis, M.D.
Plastic Surgery
Cardinal Glennon’s Division of Plastic
Surgery welcomes Alexander Lin, M.D.,
as Division Director. Dr. Lin received
his M.D. from Johns Hopkins School of
Medicine in Baltimore, Md., and completed
his fellowship in Craniofacial and
Pediatric Plastic Surgery at the University
of Pittsburgh Medical Center.
Elizabeth
Abraham, M.D.
Nephrology
Adnan
Cutuk, M.D.
Orthopedics
Barbara
Braddock M.D.
Developmental Pediatrics
Kasey
Davis, M.D.
Psychology
Ron Mitchell, M.D.
“Pediatric OSA: Outcomes of
Surgical Therapy.”
Tel-Aviv Sourasky Medical
Center: Department of
Otolaryngology Head and Neck
Surgery. June 18, 2010.
Miniseminar-Pediatric OSA.
Inter-American Pediatric
Otolaryngology Meeting.
Panama City, Panama.
July 30, 2010.
Publications
Dr. Christina Plikaitis joins Glennon
after completing her fellowship in Pediatric
Plastic Surgery at the University of
Chicago.
Vincent
Gibbons, M.D.
Neurology
David
Greenberg, M.D.
Orthopedics
Paruthi S, Chervin RD
“Approaches to the assessment of
arousals and sleep disturbance in
children.” Sleep Med. 2010 Jul 8.
1

Inpatient Satisfaction
Scores Soar in 2010!
In July 2010, several of Cardinal Glennon’s
inpatient satisfaction scores reached the
99th percentile in Press Ganey surveys.
Transitional Care Unit
99 th percentile
Neonatal Intensive Care Unit
99 th percentile
Inpatient Unit: 4-North
99 th percentile
SSM Cardinal Glennon building St. Louis’
first pediatric hybrid catheterization lab
Cardinal Glennon Children’s Medical Center will elevate children’s
heart care in the metro area with the addition of a pediatric hybrid
catheterization suite, the first in St. Louis.
The suite will allow cardiac cath interventions and heart surgery to
be performed in one session, reducing procedure time and providing
advanced cardiac care at one time rather than an extended period of time.
For many infants, the procedures performed in the hybrid cath lab are lifesaving.
Using catheter-based interventions, surgeons are sometimes able to
address problems without using open cardiac surgery and cardiopulmonary
bypass. For a small infant or those younger than one year, the possibility of
wellness without an invasive procedure is significant.
Fetal Care Institute constructs new space
The St. Louis Fetal Care Institute will open a new clinic suite at Cardinal
Glennon, bringing patients closer to pediatric specialists.
In anticipation of longer stays for out-of-town patients or those meeting
with several specialists in one day, the suite will include two nesting rooms
complete with a couch, recliner, TV and computer. There will also be an
examination and treatment room for ultrasounds and treatments such as
amniocentesis. A monitor on the wall will make sure everyone in the room
can see the images.
Finally, a conference room large enough for a family and several specialists
will provide ample space for consultations.
Wireless Capsule Endoscopy
Gastroenterologist performs first pediatric capsule endoscopes in St. Louis
On June 24, Ajay Jain, M.D., of the Division of Pediatric
Gastroenterology performed the first unique wireless capsule
endoscopy in St. Louis. Since then, Dr. Jain has completed
five capsules for SSM Cardinal Glennon patients.
a way to directly visualize the small bowel, thus significantly
helping this large group of patients. This also makes Cardinal
Glennon the only pediatric hospital in the Saint Louis area to
have an in-house capsule endoscopy facility.
2
The capsule provides direct visualization of the small bowel,
an area inaccessible to regular endoscopy and colonoscopy.
Though roughly the size of a Tylenol pill, the swallowed
capsule houses:
• A video camera
• Lenses and battery
• Light source
As it traverses through the digestive system, it takes pictures
and video, which are transmitted to a recorder via electrodes
placed on the patient. Patients are free to move, go home or
go to school during the procedure.
In patients with chronic abdominal pain, small bowel
Crohn’s disease or unidentified GI bleeding who might have
remained undiagnosed or misdiagnosed, the capsule provides
For more information and to earn CME credit from
Saint Louis University, watch Dr. Jain’s presentation,
“Wireless Capsule Endoscopy,” on Pediatrics on Demand!
www.pediatricsondemand.com
Username: ds\r010-online • Password: webcme
Questions Email pediatricsondemand@ssmhc.com.

1 Year Later
Andre Byrd, Jr., has been small since the moment he was born in April 2009.
Now, 17 months old, his size is the least of his mother’s worries.
“He is just so energetic we can barely keep up with him sometimes,” Sahreese
Byrd says. “For everything he’s been through, you think you would be able to
tell, but you can’t. I mean, he’s small, but everything else is great. He is such a
blessing. He really is.”
Andre was born 15 weeks early and without a heartbeat. He was quickly
resuscitated and transferred from SSM St. Mary’s Health Center to Cardinal
Glennon’s NICU. Neonatologists Michael French, M.D., and Greg Booth, M.D.,
treated Andre for hypotension, Patent Ductus Arteriosus (PDA), sepsis and lung
disease.
Since then, Andre has certainly lived up to how his parents immediately described
him more than a year ago — Andre is a fighter. Not only did he survive, but he
left his NICU bed three weeks before expected, taking only a heart monitor and
1/16 liters of oxygen. He has returned a couple times, once for a week-long stay
in the PICU for an episode that required him to be re-intubated.
Check up with Andre
Check in with the Division of Neonatology
“Compared to how early he was, he actually did really well,” she says. “He didn’t
get any colds this winter, any flu, it has just been the occasional wheezing. He
has come in for some breathing treatments and made lots of friends with the
respiratory staff.”
Andre Byrd, Jr., 17-months, was born at 25 weeks gestation and
without a heart beat. Cardinal Glennon neonatologists successfully
cared for him, sending him home three weeks early.
Within the last year, the Division of Neonatology has also welcomed a new Director. Richard Cooke, M.D., joined Glennon’s
16 neonatologists as Division Director when William Keenan, M.D., stepped down in late 2009. Dr. Cooke says he joined
Cardinal Glennon because of the hospital’s mission to provide compassionate care to everyone. He was also drawn to the
hospital’s academic relationship with Saint Louis University.
Dr. Cooke’s clinical and research interest is in fetal-infant nutrition. He notes that nutrition plays a critical role in determining
outcomes, but that many unanswered questions remain about feeding high-risk infants.
“Research is simply a way of giving the best possible care,” Dr. Cooke says. “We must know how to feed these infants in order
to ensure they have the best possible short-term and long-term results.”
Though he has stepped down as Division Director, Dr. Keenan
continues to serve babies internationally. In June, the Helping
Babies Breathe program officially launched in Washington, D.C.,
and 100 Master Trainers received training. Dr. Keenan played
a critical role in the development of the program, which was a
restructuring of the Neonatal Resuscitation Program that he helped
develop and has trained 2.2 million providers worldwide.
Sahreese Byrd and her son Andre Byrd, Jr., pose with two of their friends from the
Cardinal Glennon NICU. From left: neonatologist Greg Booth, M.D., and hospitalist
Stacey Monaco, M.D.
Also, on Oct. 2, Dr. Keenan received the prestigious Virginia
Apgar Award from the American Academy of Pediatrics at the AAP
National Conference & Exhibition in San Francisco, Calif. He was
recognized as a pioneer in the field of neonatal resuscitation and
as one of the founding members of the Neonatal Resuscitation
Program. In the U.S., the death rate for babies has dropped
an estimated 70 percent since the adoption of the Neonatal
Resuscitation Program in 1987.
3

Access Center assists an early morning delivery
Shortly after giving birth on Aug. 11, Portia Rushing learned
her son, Padien, was being transferred from Touchette Regional
Hospital to Cardinal Glennon for “an episode with his
heart.”
At 5:58am, Jason Kesselring, M.D.,
dialed the Cardinal Glennon Access
Center to discuss Padien’s elevated
heart rate of 280 and apparent supraventricular
tachycardia (SVT). To
determine whether or not a transfer
was needed, he quickly consulted
with a neonatologist as well as cardiologist Renuka Peterson,
M.D., who advised medication for the rhythm.
“The Access Center just makes everything easier and more efficient,”
Dr. Kesselring says. “You don’t have to remember the
NICU’s number, the ED’s number or the transports team’s
number. You just dial and get someone who knows what they
Do You Know:
How to Use Weight Management
Do you know: “During the past two decades, the prevalence of children who
are obese has doubled, while the number of adolescents who are obese has
tripled.” (American Academy of Pediatrics).
are doing immediately.”
Initially, parents of overweight and obese children should seek advice from
their primary care provider. However, when more intensive weight management
services are needed, it is best to use a pediatric weight management
program, as services for adults or commercial weight loss programs are often
not appropriate for children because of developmental and nutritional issues.
• Due to growth and development, tracking progress in children goes
beyond body weight. Growing children must be carefully weighed
and measured at each visit to calculate BMI and plot this value on a
growth curve or calculate a standard deviation score. In adults, this
is not necessary, as body weight or BMI alone are sufficient to track
progress.
• Children have different nutritional needs than adults, especially in
terms of portion size and daily allowances of nutrients.
• Most importantly, children and many adolescents are not fully independent
in terms of living a healthy lifestyle. They are easily influenced
by adult role models, social cues, advertising, the environment
and peer pressure. It takes a skilled team of pediatric specialists to
recognize these influences and work within the context of the family
and social environment to care for the child.
The Access Center was the first in St. Louis and is answered
24 hours a day, 7 days a week by transport-trained nurses.
Physicians are also available any time
to consult on possible transfers or
basic questions. According to Access
Center Director Karen Zahn, the
Center has made transferring NICU
babies quick and convenient for offsite
locations.
“Physicians can consult directly with
the neonatologist and any other specialist to determine immediately
if the baby needs to be transferred or not, and what
they should do in the mean time,” Zahn says. “It makes everything
more efficient for the physicians, transport team and,
most importantly, the patient.”
Top Row from Left: Kathryn Helling, RD, Clinical Nutrition; Amy
Ford, PsyD, Psychology. Bottom Row from Left: Elizabeth Babusis,
M.D., Lipid Disorders & Weight Loss; Nadim Kanafani, M.D.,
Endocrinology & Diabetes; Kathy Spranaitis, PNP, Gastroenterology;
Joel Nadler, PhD, Psychology
Cardinal Glennon’s Weight Management Program includes pediatric specialists from endocrinology, lipid disorders, psychology,
nutrition and gastroenterology. Patients work closely with providers who support behavior change through collaborative
goal setting and motivational interviewing techniques. Education focuses on medical, behavioral and nutritional aspects of pediatric
weight management. A patient’s initial visit lasts two to three hours and includes a one-hour nutrition class and healthy
lunch. Depending on individual needs, patients can be seen as often as every three to four weeks.
4
To refer a patient, please have families call (314) 268-2700 ext 1695.

Glennon Expands Cochlear Implant Program
The Division of Otolaryngology and the
Department of Audiology have recently
expanded their services, offering comprehensive
hearing assessments to patients,
full ENT and Audiology services at two
locations — Cardinal Glennon and St. Anthony’s
Medical Center in St. Louis — and
dedicated cochlear implant audiologists.
The Cochlear Implant Program, led by
ENT surgeon Anita Jeyakumar, M.D.,
cares for all children with moderate to
severe hearing loss. Prior to making the
decision to implant, each patient visits
extensively with surgeons, audiologists,
social workers and experienced nurses.
The comprehensive approach also ensures
coordinated visits with other specialities;
hearing tests with or without sedation;
communication with referring physician
Cochlear Implant Program Director Anita Jeyakumar,
M.D., performs a cochlear implant.
Diversions
within 24 hours of appointment; and education
for parents.
“Our goal is to be a resource to parents
and children as they navigate through the
child’s hearing loss,” Dr. Jeyakumar says.
“For some, implantation is the solution,
but for others it is not. Our belief is that
every child deserves to hear, and we will do
everything we can to provide a solution.”
Full ENT and Audiology Services @
SSM Cardinal Glennon
1465 S. Grand Blvd, St. Louis, MO 63104
ENT: 314.268.4010
Audiology: 314.577.5671
St. Anthony’s Medical Center
10010 Kennerly Rd., St. Louis, MO 63128
ENT: 314.842.3535
Audiology: 314.577.5671
Andrew Sutton Physician Services Team Leader
Dining
Acero
www.fialafood.com
314.644.1790
I’m hesitant to tell you about Acero.
Not because the food or the service
falls short of outstanding. Quite the
contrary, this place is so fantastic,
and so small, I want to keep it all to
myself.
Tucked at the end of a row of shops in Maplewood, this
quaint spot focuses on perfecting the rustic Italian meal. Acero
is owned by Jim Fiala (Liluma, Terrace View, The Crossing)
and excels in providing a memorable experience through
house-made pasta, imaginative dishes and attentive service.
The three courses for $30 has to be the best deal in town. I’ve
been twice, and I honestly feel I’m committing a crime for
not paying more for my meal.
Tricia and I both enjoyed the three course option during our
last visit. We shared a couple “quartinos” of Soave, a crisp,
citrus-forward wine from Italy, and kicked things off with the
Acero salad, a blend of romaine, egg, onion, salumi and herb
vinaigrette. The saltiness of the salumi, the heartiness of the
egg and the zest of the vinaigrette all sing together in a delightful
chorus. The delight carried through in to my second
course, tagliatelle with morel mushrooms. The freshness of
the house made pasta shines through and plays against the
olive oil and earthiness of the mushrooms. Honestly, I could
eat the tagliatelle as a meal, and I’m sure many people do.
Tricia raved about her entree, a fresh-caught walleye, and I
was blown away by my scallops. An imaginative presentation,
the scallops are prepared with mandarin oranges, which lend a
pleasing citrus flavor.
Desserts are quite tasty. The highlights include the affagato -
a shot of espresso poured on top of vanilla ice cream, and the
warm chocolate torte, which also comes with a side of vanilla
ice cream.
Acero is small. The food is excellent. The service is personable.
Reservations are recommended.
Beverages
Tricia and I recently popped open a bottle of 2007 Delas “St.
Esprit” Cotes-du-Rhone. The Delas is a fine example of the
outstanding Rhone wines cranked out in the 2007 vintage.
An excellent value ($15.00), this blend of 75% Syrah and
25% Grenache paints the glass a deep garnet color. The nose
reveals chocolate, cedar, caramel and cola. Fruit-forward,
layered, and with moderate tannins, black cherry stands out
as the dominant player on the palate. A pleasing, medium
finish rounds out this very enjoyable wine. Get some soon.
The word is out on the value and quality of the 2007 Rhone
vintage.
5

What is independence For many children it’s
the first few moments away from their parents’
grasp, a slumber party in a friend’s basement
or the first time they get the car keys. But for the patients
within the Division of Pediatric Urology, it’s a lot of things
people don’t want to talk about.
Voiding dysfunction, incontinence and genital anomalies
separate children from social norms and severely affect self
esteem, bodily function and social interaction. So why
doesn’t anyone want to talk about it
“Many times, it is difficult for parents to find a venue to be
heard and to thoroughly discuss these issues,” says Division
Director Anand Palagiri, M.D. “But they are extremely
important to quality of life and social acceptance, hence our
mission to bridge the gap and address the problems either
medically or surgically.”
Dr. Palagiri and partner Casimir Firlit, M.D., provide comprehensive
care, commonly treating conditions such as:
• Undescended Testicle (Cryptorchidism)
• Hypospadias (Abnormal urethral opening)
The Silen
SSM Cardinal Glennon Div
• Hernia
• Hydrocele
• Vesicoureteral Reflux
• Obstructed Kidneys (UPJ obstruction)
• Hydronephrosis (Prenatal/Postnatal)
• Kidney Stones
• Nocturnal Enuresis (Bed Wetting)
• Voiding Dysfuntion
• Circumcision and its complications
• Urinary/Fecal Incontinence
But they certainly don’t do it alone. Within their division
they call upon clinical coordinator Kelly Lepsky, RN, surgical
physician assistant Jenny Deyto, PA, and clinical nurse Louisa
Salvin, RN. With more than 20 years of experience, nurse
practitioners Jeanne Hermann, PNP, and Nancy VanCleave,
PNP, offer high-quality care as they triage patients through
weekly clinics and address dysfunctional voiding.
This group also works tirelessly to ensure care to expectant
mothers whose prentatal ultrasounds reveal urinary tract mal-
Treating Vesicoureteral Reflux
6
After his first day of kindergarten, Donald Horvath, 5, receives a
renal and bladder ultrasound at his first appointment with urology
nurse practitioner Jeanne Hermann, PNP. Donald was fully toilet
trained when he was 2 years old, but within the last year he has
experienced several accidents along with a urinary tract infection. In
her effort to rule out any anatomical abnormalities, Jeanne utilizes
diagnostic imaging in the form of a renal ultrasound and a voiding
cystogram.
James Shipley, 5, awaits his turn for surgery. Dr. Palagiri
and his team schedule a day for endoscopic injection
procedures every eight to ten weeks. Today they completed 11
cases. Nurse practitioner Nancy VanCleave, PNP, diagnosed
James with VUR and addressed his dysfunctional voiding.
With no improvement from conservative management,
Dr. Palagiri suggested the minimally invasive injection
procedure.
Dr. Palagiri completes James Shipley’s 20
deflux injection procedure. He inserts an
through the urethra and up into the blad
he passes a tiny needle through the endo
dispenses the gel (deflux ) around the ur
ing to create a mound that stops urinary
Over time, the gel combines with fibrobl
collagen, which stabilize the position an
implant. Afterward, Dr. Palagiri met wi
family. He told them James will have no
restrictions and can return to school the

t Service
ision of Pediatric Urology
formations such as hydronephrosis, posterior urethral valves
and bladder extrophy. For many mothers, early diagnosis
and a prenatal consultation with pediatric urologists provides
comfort as they know their baby is going to be cared for possibly
prior to delivery or quickly thereafter.
Many of urology issues also require the expertise of other
pediatric specialists such as Nephrology, Radiology, Sleep
Medicine, Neurology, Gastroenterology, Anesthesiology and
Neonatology.
When seeing a patient in clinic with nocturnal enuresis (bedwetting),
Jeanne and Nancy often consider whether or not
the patient is a candidate for Sleep Medicine Specialist Shalini
Paruthi, M.D., especially if everything anatomically is working
properly.
“It’s important we work together to ensure we provide the
most comprehensive diagnosis,” Dr. Paruthi says. “Complications
such as enuresis can be devastating to a child’s self
esteem and restrict their activities. I recently had a teenage
patient who had never been on a sleep over because of nightly
enuresis. She was very ashamed.”
The Division of Urology also stays on the leading-edge of care
with education about the newest techniques and technologies
available to pediatric surgeons. This winter, Dr. Palagiri
and Dr. Firlit will begin using the robotic da Vinci Surgical
System for routine surgeries that, in the past, were only performed
through an open incision. Pediatric urology procedures
such as pyeloplasty, ureteral reimplantation and partial
or total nephrectomy can now be performed in a minimally
invasive fashion with the use of the robot.
However, these surgical advances do not overshadow the fact
that many of the Division’s patients need much more than
surgical care, Dr. Palagiri says.
“When we take a patient under our care we understand we
are responsible for the entire patient — medically, surgically
and emotionally,” Dr. Palagiri says. “We also understand that
a lot of the conditions we address are extremely taxing on the
child’s family, and we pride ourselves on comforting parents
and openly discussing any of their concerns.”
Vesicoureteral reflux is a condition in which urine backs up from the bladder into the kidney. For many children, this is caused by a faulty valve at the junction of the ureter
and the bladder. It should operate as a one-way valve. Instead, it operates as a two-way valve and can allow urine in the bladder to flow backwards (reflux) into one or both
ureters and kidneys. Reflux is dangerous when there is an infection in the bladder because it makes it much easier for bacteria to travel up the ureters and enter the kidneys
where it may infect and scar them. Treatment for persistent reflux include both endoscopic injection for minor reflux and open surgery (reimplant surgery) for severe reflux.
-minute
endoscope
der. Then
scope and
eteral openreflux.
asts and
d size of
th James’
physicial
next day.
Kaitlyn Wright, 8, models an anesthesia mask prior to her surgery. Kaitlyn
would undergo a Bilateral Extravesical Ureteral Reimplant. With a success
rate of 98 percent, this is a common procedure for Dr. Palagiri and his team to
perform for a child with severe reflux.
Dr. Palagiri isolates the ureter as he performs an ureteral reimplantation to
correct severe VUR.
7

Silent Service
Reconstruction for Acceptance
The moment her son, Gavin, was born, Nikki Mitchell knew
something was wrong. An obstetric nurse from Hannibal,
Mo., Nikki knows what a male baby’s body should look like,
but for her son, something was different.
Gavin was born with a genital anomaly known as hypospadias.
Hypospadias is a common birth defect, occurring in one
out of every 150 to 300 boys.
It is a condition in which the urethral opening does not form
completely to the tip of the penis. Instead, the opening may
be located anywhere along the underside of the penis. While
the urethral opening is most often found near the head, it also
may be located from the middle of the penile shaft to the base
of the penis or even behind the scrotum. Gavin’s hypospadias
was of the latter, occurring in only 20% of all hypospadias. In
severe cases such as Gavin’s, the penis will also have downward
curvature, a condition called chordee.
for Dr. Palagiri, specifically about anesthesia and pain.
Dr. Palagiri told her he calls daily on the expertise of
Cardinal Glennon’s pediatric-trained anesthesiologists who
not only provide top-level care during the procedure, but
manage pain post-operatively as well.
From a mother’s point of view, Nikki asked about Gavin’s
emotions – will he be scared Before going to the operating
room, Child Life Specialist Colleen Brone, meets with
children to find ways to calm their nerves or make their
trip to the operating room easier. Also, Cardinal Glennon’s
operating rooms allow children to watch movies as they fall
asleep.
“I’m coming from the perspective of a mother and a nurse,”
Nikki says before Gavin goes to the operating room, “and I
feel comfortable from both perspectives with the care
Dr. Palagiri and his team have provided Gavin.
“I always emphasize to parents, especially mothers, that they
did nothing wrong,” Dr. Palagiri says. “Sometimes it’s difficult
for parents to understand how something like this can
happen, and that’s why we take the time to explain everything
and insist that there are no silly questions.”
Due to her nursing background, Nikki had several questions
“You can tell Dr. Palagiri has a family. He is so understanding
and takes the time to meet with us and then walk us
out, carrying Gavin the whole way. How often do you really
get that kind of care from a surgeon”
During the 3-hour hypospadias repair, Dr. Palagiri finally
puts Nikki’s worries to rest for the first time in 20 months.
First, he works out the mechanics, straightening the penis
and creating a tube from the hole to where it should be.
Then he focuses on the cosmetics.
“It is one thing for the hole to be brought to the tip of the
penis, however, what the penis looks like afterwards is a
whole other ball game,” Dr. Palagiri says. “It’s extremely
important to the esteem of a male child. We live in a society
where it matters to have a normal-looking penis, and my
goal is to make sure the children I work with have no idea
anything was ever an issue.”
8
Gavin Mitchell, 17 months, smiles with his parents prior to surgery.
Gavin was born with a severe hypospadias, which Dr. Palagiri corrected
in a 3-hour hypospadias repair.
“You can tell Dr. Palagiri has a
family. He is so understanding
and takes the time to meet with
us and then walk us out, carrying
Gavin the whole way. How often
do you really get that kind
of care from a surgeon”
— Nikki Mitchell, mother

Silent Service
Reconstruction for Independence
Treon McKinzie, 12, is ready for independence, but first she
must depend on pediatric urologist Casimir Firlit, M.D.
Born with myelomeningocele, lumbar lesion, with hydrocephalus,
Treon has a VP shunt for hydrocephalus, which was
placed at birth. Despite medical management and intermittent
bladder catheterization, at 3 years old she had increased
dilation of both kidneys as well as development of bilateral
severe vesicoureteral reflux with frequent urinary tract infections.
In order to protect her kidneys from damage, a vesicostomy
was completed in which the bladder wall was brought to the
abdominal wall and an opening was created in the lower abdominal
wall below the umbilicus to allow urine to flow out
of the bladder continuously. This has protected the kidneys
well, but required her to wear diapers at all times due to the
continuous, unobstructed flow of urine out of the bladder.
“It’s important for children like Treon that we find solutions
for issues like continence,” Dr. Firlit says. “She has a right to
live like any other child and have that independence. She is
the reason I do what I do.”
Dr. Firlit, Treon and Treon’s mother elected to complete two
stages of reconstructive surgery to maximize the outcome.
During Stage 1, the vesicostomy was closed and a suprapubic
tube was place in the bladder, exiting through the abdominal
wall in her left lower abdomen. The tube is connected to a
drainage bag for approximately four weeks, allowing the bladder
to fully heal.
Stage 1 also included the creation of a tubulzarized Appendico
Cecostomy, often referred to as an ACE. This surgery uses the
appendix to create a continent channel and a small opening in
the right lower abdomen. Through this opening, Treon will be
able to give herself a low volume enema while sitting on the
toilet, emptying her entire colon of stool and allowing her to
be continent of stool between treatments. With teaching and
practice, she will be able to do this procedure independently,
allowing her the opportunity for a self-directed and responsible
quality of life.
After healing of her bladder is confirmed by radiologic
cystogram, the bladder catheter will be plugged for increasing
lengths of time to train her bladder to hold urine for four
hours – this capacity has not been there for nine years. Once
this training is complete in about three to four months, Treon
will return to the operating room for Stage 2 – the Monti procedure
and, if necessary, a bladder neck sling should leakage
of urine from the urethra persist.
After healing from the Monti surgery, Treon will be able to
catheterize her bladder intermittently through a small opening
in the left lower abdomen, with improved continence between
catheterizations.
Fereius Casimir et pliquo Firlit, te velicate M.D., (right) culla quae performs mod Treon’s que nihitatium Stage 1 procedure, coris mo et, which velles includes mo inum the dolorer creation ferrore of the hentis tubulzarized sundund Appendico empellatinto Cecostomy. cupid ut rere quam ipsandi beatur
sum reris atur Abo. Ut molestiur Genectur
9

Left: Using a video screen, Anand Palagiri, M.D., navigates through the ureter to the kidney to find Irhad Sehovid’s kidney stone. Using a laser fiber, he disintegrates the
kidney stone and pulls out the smaller pieces. Right: Dr. Palagiri directs the laser fiber to the kidney stone and blasts it apart.
It was a Monday morning at 5:00am when Irhad Sehovic, 15,
woke up with a terrible pain in his left side.
Silent Service
Pediatric Stone Center
factors is initiated. What we do now will impact these children
positively for the rest of their lives.”
10
“I tried eating something, but it wouldn’t go away,” he says.
“It was the worst pain I have ever experienced.”
When Irhad began vomiting, his parents rushed him to the
emergency room. When his vomiting persisted even after
medication, he was sent to Cardinal Glennon via ambulance.
Emergency physicians diagnosed him with a kidney stone.
Little did Irhad know he had been taken to the right place. In
2007, Cardinal Glennon launched the Midwest’s first Pediatric
Kidney Stone Center to address the painful problem that
is increasing among young children.
Kidney stones are caused by diet, dehydration or genetic
factors, which must be addressed to keep stones from reoccurring.
However, for children, once a stone has formed, they
are usually difficult to pass due to the smaller caliber of the
urinary tract. According to Dr. Palagiri, there is no stone the
Center can’t remove in any child.
“Kids have a bright future ahead of them when we deal with
and treat the stones early on,” Dr. Palagiri says. “Currently, we
offer state-of-the-art, minimally invasive techniques to remove
stones. In collaboration with Dr. Ellen Wood and her team of
nephrologists, a thorough evaluation of the etiology and risks
To treat kidney stones, Dr. Palagiri established a protocol specifically
tailored to children given the delicate nature of their
urinary tract. It usually follows these steps and requires up to
three separate procedures:
1. Placement of a ureteral stent: The stent protects the
kidney and ureter and alleviates the obstruction caused
by the stone. At the same time, it dilates the ureter prior
to the second procedure.
2. Procedures:
• Holmium Laser: Using a tiny camera and a scope,
Dr. Palagiri inserts a small laser fiber that targets
and breaks apart the stone so it can be removed in
multiple pieces.
• Extracorporeal Shock Wave Lithotripsy (ESWL):
If the stone is in the kidney and can be seen on
diagnostic x-ray, the Center may elect to use sound
waves to target the stone. The stone is pulverized
into sand and is much easier to pass. This option
requires no invasion of the body.
3. Stent Removal: When a stone requires manipulation to
be removed, often times the ureter can swell shut after
the intervention. In these cases, Dr. Palagiri will leave a
stent behind to protect the ureter. He then removes it

da Vinci Surgical System
This winter, the Division of Pediatric Urology
at Cardinal Glennon will begin using the da
Vinci Surgical System.
The robotic system offers even smaller
instruments, which are beneficial for the
smaller bodies of pediatric patients. Anand
Palagiri, M.D., says the da Vinci is especially
useful for procedures that require fine sewing,
such as kidney procedures.
The da Vinci also allows for procedures once
performed openly, to be completed minimally
invasively. These include:
• Pyeloplasty
• Ureteral reimplantation
• Partial or total nephrectomy
Features of the da Vinci Surgical System
include:
• High-resolution, 3D video
• Fully articulating instruments
• State of the art robotic technology
Benefits for patients include:
• Shorter length of stay
• Lower complication rates
• Less post-op pain
• Superior outcomes
one week later.
4. Testing: Once the stone is removed, it is sent for stone
analysis. A 24-hour urine collection is also completed by
the patients several weeks after the surgery. These values
often help determine whether there are any metabolic
abnormalities. Urology works closely with the Division
of Nephrology based on the results of this testing. If
there are concerns on the molecular level, the patient
will work with nephrologists and possibly clinical nutritionists
to determine the needed course.
5. Basic Preventions: To avoid stones, Dr. Palagiri suggests
limiting dark-colored sodas, iced tea and salt. The stone
center’s motto is as follows: “The solution to pollution is
dilution,” so drink lots of water and remain hydrated.
One week after his painful morning, Irhad underwent laser
lithotripsy with the homenum laser. Dr. Palagiri inserted a
scope through Irhad’s urinary tract and into his kidney. He
located the stone and inserted the laser fiber, which successfully
disintegrated the stone. The remaining pieces were then
removed from the urinary tract.
“My advice would be to not do what I
did,” Irhad says. “Drink all the water
you can. But, if you do end up here
at Cardinal Glennon, you’ll probably
end up having a good time.”
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Q&A
Anand Palagiri, M.D.,
Division Director, Pediatric Urology
Front from left: Nurse Practitioners Nancy VanCleave, PNP, and Jeanne Hermann, PNP;
clinical coordinator Kelly North-Lepsky, RN. Back: Anand Palagiri, M.D.
Q: What is the most challenging part of your job
A: In pediatrics, parents entrust you with the care of their
child and that is not something we take lightly. We want to
make sure that child has a great future. It’s a daunting task,
but I look forward to the challenge. I want to do everything
and anything in my power to make sure the parent has
absolute trust in the services we provide.
Q: Why is your Division important to the health care of
children
A: Continence equals independence. It is extremely important
to parents and their children and has a lot of social impact.
Urology also has an evolving role as diets change, not always
for the better, creating issues such as kidney stones that we are
witnessing at younger ages. These issues need to be addressed
at an early age so we can equip these children with what they
need to ensure a healthy future.
Q: Why did you choose pediatric urology
A: As a urologist, my father played a pivotal role in my career
choice. I grew up watching him care for patients and make
their quality of life better. During medical school and urology
residency, I had an excellent exposure to colleagues in the field
specific to pediatric urology.
I’ve always enjoyed the surgical reconstruction as well as
the challenges urologic problems pose in children. Urologic
problems are not widely known because of the personal
nature of the issues. Those who are in the specialty dedicate
their time to the patient and their families to validate their
concerns. We understand these concerns are never trivial,
especially in terms of reconstruction of the genitalia and
voiding issues. These are a huge part of a child’s self esteem in
today’s society.
Q: How has technology impacted your specialty and how
will it in the future
A: Technology has improved significantly in terms of size of
instruments. Because of this, we are tackling procedures that
were once foreign to pediatric urologists due to the lack of
instrumentation. We as technicians should strive to improve
just not our skills, but our tools for surgical perfection.
To reach DR. Palagiri
Please Call:
(314) 268-2700
ext 6843.
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Pediatric Urology
Faculty
Anand Palagiri, M.D.
Division Director, Pediatric Urology
B.A. Music/B.A. Biology: Washington University, St. Louis, MO
M.D. with Distinction in Research: Saint Louis University School of
Medicine, St. Louis, MO
Residency in Urology: Saint Louis University School of Medicine,
St. Louis, MO
Fellowship in Pediatric Urology: Saint Louis University School of Medicine,
St. Louis, MO
Diplomate, American Board of Urology &
Certificate of Added Qualification, Pediatric Urology
Clinical Assistant Professor of Urology: Saint Louis University School of
Medicine, St. Louis, MO
Casimir Firlit, M.D., Ph.D.
M.S. in Pharmacology: Loyola University of Chicago, Chicago, IL
M.D.: Loyola University of Chicago, Chicago, IL
Ph.D. in Pharmacology: Loyola University of Chicago, Chicago, IL
Fellowship: Lederle Medical Student Fellowship in Research, Loyola University
of Chicago Medical School, Chicago, IL
Clinical Fellowship in Pediatric Urology: Children’s Memorial Hospital/
Northwestern University, Chicago, IL
Clinical Preceptorship in Pediatric Renal Transplantation: Children’s
Memorial Hospital/Northwestern University, Chicago, IL
Jenny Deyto, PA C
Bachelor of Arts - International Affairs: The George Washington University,
Washington, D.C.
Master of Medical Science - Physician Assistant Studies: Saint Louis
University, St. Louis, MO
Pediatric Urology
Staff
Jeanne Hermann, RN, CPNP
Bachelor of Arts-Biology: Webster University, St. Louis, MO
Bachelor of Science in Nursing: Saint Louis University, St. Louis, MO
P.N.P. Certification: SSM Cardinal Glennon Children’s Medical Center,
Saint Louis University, St. Louis, MO
Nancy VanCleave, RN, CPNP
Bachelors of Science in Nursing: St. Louis University, St. Louis, MO
P.N.P. Certification: SSM Cardinal Glennon Children’s Medical Center,
Saint Louis University, St. Louis, MO
Kelly North-Lepsky, RN
Clinical Coordinator
Associates Degree in Nursing: St. Louis Community College, St. Louis, MO
Bachelor of Science - Criminal Justice Studies: University of Missouri Saint
Louis, St. Louis, MO
Louisa Salvin, RN
Urodynamics, Myelomeningocele Clinical Nurse
Bachelor of Arts: Wellesley College, Wellesley, MA
Diploma - Nursing: Newton Wellesley School of Nursing, Newton, MA
To reach our faculty or staff, please call (314) 577-5334.
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