Gary A. Levengood, M.D., Board Certified Orthopedic Surgeon and Founder of Sports Medicine South L.L.C, has been practicing for nearly 20 years offering the most advanced, orthopedic treatments to help restore his patient’s natural mobility. In an effort to achieve superior results, Dr. Levengood offers customized knee resurfacing implants designed uniquely for each patient’s anatomy, decreasing the amount of bone removal and pain after surgery.
Dr. Levengood has performed more than 1,000 total knee replacements (TKRs), but believes that it’s not the only option for people suffering from knee pain. Since TKRs only come in a set of 5-6 pre-determined sizes for patients, physicians must fit the patient’s knee to the implant. A traditional TKR also requires complete removal of the ends of the femur (thigh bone) and tibia (shin bone), often including one or both of the ACL and PCL. This can result in a painful procedure and knee kinematics that can feel very different than the native kinematics of the patient, something that many physicians will hear from patients when they talk about how it feels.
Dr. Levengood provides counsel to each of his patients based on their age, activity level and other mitigating factors in their life. For younger or more active patients with osteoarthritis in just a part of their knee, he will recommend patient-specific implants that can provide patients with a less invasive, bone-sparing alternative to TKR surgery. Dr. Levengood has regularly prescribed an advanced line of patient-specific implants developed by ConforMIS since last year. He has helped to bring the latest innovation, the iDuo® G2, to market by participating in the early evaluations of the implant by a limited group of surgeons prior to broad commercial release.
Personalized partial knee implants are designed to the exact shape and size of a patient’s knee preserving far more bone and tissue than a standard knee replacement and helping to maintain a more natural feeling knee. Because they are more minimally invasive, treating only the diseased compartments, they can also preserve all ligaments, an important driver of knee kinematics.
The iDuo G2 is a personalized bicompartmental knee resurfacing device that preserves more of a patient’s own bone and all of their ligaments for those suffering from knee pain in two out of the three compartments of the knee. ConforMIS also offers a custom, personalized solution unicompartmental device, the iUni® G2, for patients whose arthritic damage is limited to one compartment of the knee. These implants also simplify the surgical procedure, allowing for a less traumatic surgery for the patient and to safeguard further surgeries. Dr. Levengood has performed more than 20 patient-specific implants thus far, and says his patients are happy with the end results.
Dr. Levengood’s specialties include arthroscopic surgery, sports medicine, and joint arthroplasty. In addition, he supports the local community by serving as Team Physician for Brookwood High School, Orthopedic Consultant for Loganville High School, and Medical Director of Gwinnett Gymnastics Center. He has traveled internationally with the U-17 national men’s soccer team as their physician.
Dr. Levengood is the current Team Physician of the Georgia Force, a Gwinnett arena football team and the Atlanta Silverbacks Soccer team; he is also the Medical Director for the Georgia State Soccer Association’s Olympic Development program and is Chief of Orthopedics at Gwinnett Medical Center. Formerly, he served as the Team Physician for the Atlanta Silverbacks from 2000 – 2007.
Nancy Collop, MD, a nationally recognized expert in sleep medicine, has been named director of the Emory Sleep Center. She also will have a primary appointment in the Emory School of Medicine as professor of medicine in the Division of Pulmonary, Allergy and Critical Care Medicine, and a secondary appointment as professor of neurology.
Collop comes to Emory from Johns Hopkins University, where she served as a professor of medicine in the Division of Pulmonary and Critical Care Medicine and as the medical director of The Johns Hopkins Hospital Sleep Disorders Laboratory.
Collop will work in close partnership with experts from all disciplines of medicine to further the Emory Sleep Center’s interdisciplinary approach to treating patients with a variety of sleep disorders.
“Sleep medicine spans the spectrum of all medicine,” says Collop. “You can look at any part of medicine and find that sleep has an effect. I look forward to leading the collaborative work and research we will be doing with our colleagues in neurology, pediatrics, nursing, otolaryngology, oral and maxillofacial surgery, and other areas to provide a comprehensive diagnosis and treatment plan for our patients.”
Collop graduated summa cum laude from Edinboro State University in Edinboro, Pennsylvania and earned her medical degree at Pennsylvania State University College of Medicine, where she was awarded the Roche Clinical Psychiatry Research Award and was elected to the Alpha Omega Alpha Honor Society. Collop completed her internal medicine internship and residency at the Medical College of Virginia and a pulmonary/critical care fellowship at the University of Florida. She was a recipient of the Research Fellowship Award from the American Lung Association of Florida.
She has been awarded several prestigious honors including “Best Doctors in America,” Baltimore’s “Top Doctor” in pulmonary and critical care medicine and sleep medicine, the Al Soffer Award for Editorial Excellence and the College Medalist by the American College of Chest Physicians, Distinguished Alumna for Natural Sciences (Edinboro University), and the Helmut S. Schmidt Award (American Board of Sleep Medicine).
Collop has served on the Board of Directors for the American Board of Sleep Medicine since 1998 and was the president from 2002-2009. She is on the Board of Directors of the American Academy of Sleep Medicine and is currently the president elect; she is also on the Board of Directors for the American Sleep Medicine Foundation. She was on the founding committee of the American Board of Internal Medicine (ABIM) Sleep Medicine Examination Committee and also serves on the ABIM Pulmonary Self Evaluation Process committee. Collop is an associate editor of the journal Chest and serves on the editorial board of Pulmonary Reviews. Her research interests include diagnostic testing for sleep-disordered breathing and standards for polysomnography.
Stuart Knechtle, M.D. recently joined Children’s Healthcare of Atlanta as Chief of Pediatric Liver Transplant Surgery, Surgical Director of the Liver Transplant Program and the Carlos and Marguerite Mason Chair for Liver Transplant Surgery.
Dr. Knechtle will also remain Chief of the Division of Transplantation and Professor of Surgery at Emory University School of Medicine as well as Clinical Director at the Emory Transplant Center and Director of Liver Transplantation at the Emory Clinic.
“Dr. Knechtle’s leading-edge surgical, research and teaching skills have earned him acclaim and respect throughout the medical community,” said Amy Hauser, Service Line Administrator for Transplant Services at Children’s. “His combination of talents will allow Children’s and Emory to stay at the forefront of transplant research, specifically in transplant immunology. We are thrilled to officially welcome him to the Children’s Transplant family.”
A leader in the field of liver and kidney transplantation, Dr. Knechtle has designed and led a variety of clinical trials in organ transplantation. He operated a National Institutes of Health (NIH) funded research lab for 17 years and continues research focused on the immunologic mechanisms of transplant rejection and immunologic tolerance. Prior to joining Emory and Children’s, Dr. Knechtle led a team at the University of Wisconsin-Madison that performed the state’s first liver transplant from a living donor, as well as the state’s first combined liver and pancreas transplant.
A member of several professional and scientific organizations, including the American Surgical Association and the American Society of Transplantation, Dr. Knechtle has presented at more than 60 international conferences and meetings. An accomplished author, Dr. Knechtle has also contributed to more than 300 research articles, publications and abstracts in the areas of transplantation and transplant immunology.
Dr. Knechtle earned his medical degree from Cornell University and completed both his residency and transplant immunology research fellowship at Duke University Medical Center. After finishing his transplantation fellowship at the University of Wisconsin-Madison Hospital Department of Surgery, Dr. Knechtle remained on staff for nearly two decades and most recently served as a Professor of Surgery and Director of Liver Transplantation.
George Gottlieb, M.D., FAAIA, FACA, Diplomate, American Board of Allergy and Immunology, in partnership with DeKalb Medical’s Kahn Outpatient Cancer Center, offers a rapid desensitization treatment program that allows cancer patients who are allergic to their chemotherapy medication to receive the drug that is most effective for their cancer diagnosis.
Until recently, allergic reactions have prevented some cancer patients from getting the best treatment available for their cancer. Allergic reactions can cause symptoms ranging from excruciating pain to vomiting,� weakness or worse, anaphylactic shock a life-threatening condition that moves quickly, causing difficulty breathing, dizziness, swelling of the tongue and bronchial tubes, low blood pressure and heart failure. ��� Patients may then need to be switched to another cancer medication that is not as effective.
�When a patient develops an allergy to an essential drug needed for treatment, we have to find alternative drugs, says Betty Castellani, D.Min., Director of the Kahn Outpatient Cancer Center. Often, the other chemo drugs are less effective or more toxic than the preferred options. This new program offered by Dr. Gottlieb provides us with the means to continue treating a patient with the drug of choice.� We are very excited to � offer this protocol to patients who have been forced to halt a treatment because of a drug allergy,� adds Castellani.
As a board-certified Allergist and Immunologist, Dr. Gottlieb spends much of his time helping patients tolerate things they need but which cause them to have allergic reactions. And he’s always looking for new ways to help his patients.� Dr. Gottlieb believed he could offer a way to desensitize patients who are allergic to chemotherapy.� He created an outpatient program at DeKalb Medical to help cancer patients whose bodies have rejected the chemotherapy medications that they need to treat their cancer.� Over the past year, he has successfully completed over 60 of chemotherapy desensitizations.� These included desensitizations for a variety of drugs used to destroy cancer cells, including carboplatin, oxaliplatin, cisplatin, retuximab and paclitaxol.� Rapid desensitization sessions last a total of 6 to 8 hours.� Patients take gentle premedications that include oral antihistamines, ibuprofen and aspirin, before the sessions.
Dr. Gottlieb says, I’m very grateful to partner with the DeKalb Medical’s Kahn Outpatient Cancer Center and� work with the outstanding pharmacists and nurses there.� The work of the pharmacist is critical. The chemo ingredients can be toxic if they are inhaled or contact the skin. The mixture has to be prepared behind a glass enclosure by a highly skilled pharmacist wearing special gloves and protective clothing.� In addition, the Center has excellent nurses and advanced monitoring equipment that allows immediate intervention if the
patient starts having a reaction to the chemotherapy.
The chemo desensitization program at DeKalb Medical is available to patients and cancer specialists in the� Atlanta area.� Those interested can call (404)294-4761 for more information.
Dr. Gottlieb received his Bachelor of Chemical Engineering from the City University of New York. He attended� New York University School of Medicine and interned at Cornell Medical School.� Dr. Gottlieb is a Diplomat of� American Board of Allergy & Immunology, Fellow of the American Academy of Allergy & Immunology, and Fellow of� the American College of Allergists.
Joseph I. Miller Jr., M.D. recently joined the Piedmont Heart Institute (PHI) as the new chief of thoracic surgery and thoracic oncologic surgery.
For more than 35 years, Dr. Miller has been a thoracic surgeon at Emory Midtown Hospital. He also has served his profession as an examiner of the Board of Cardiothoracic Surgery for the past 19 years. Recognized as one of the leading general thoracic surgeons in the United States for over 10 years (Castle-Connolly peer review), Dr. Miller has published more than 165 peer-reviewed articles and over 50 book chapters.
Dr. Miller was recently awarded the Second Century, Wadley R. Glenn, MD, Award by Emory Healthcare.
Dr. Miller has offices on the Piedmont Hospital campus and at Piedmont West Medical Office Park on Howell Mill Road, where the Piedmont Cancer Center is located.
Terence O’Loughlin, M.D. who joined Quantum Medical Radiology of Atlanta, Georgia, (QMR) in July 2009, is a neuroradiologist at Newton Medical Center in Covington. Dr. O’Loughlin also studies at facilities across the United States via Teleradiology for QMR’s sister company USTeleradiology.
Dr. O’Loughlin earned his medical degree from Boston University School of Medicine and then trained in molecular imaging, radiology and neuroradiology at Harvard Medical School and Massachusetts General Hospital. He then completed a transitional internship at The Cambridge Hospital. While at Harvard University and Massachusetts General Hospital he completed a residency in radiology and a clinical fellowship in neuroradiology.
Dr. O’Loughlin has been awarded honors from the American Heart Association and National Institutes of Health for his work during his biophysics and molecular imaging training fellowships. He also presented and published many industry works and is a member of the American College of Radiology and other medical affiliations.
A Second Chance — A “Late Start” in Medicine is Rewarding
By Helen K. Kelley
Dr. Rutledge Forney has always been a problem solver. First, she used that ability as a successful management consultant. Today, she’s a problem solver in her second career as a medical practitioner.
Growing up in Birmingham, AL in the 1960s, young girls were generally steered toward becoming homemakers and mothers and, just to be safe — in the event they didn’t marry — were encouraged to select a “gentler” career path than their male counterparts, such as teaching or bookkeeping. So, even though Forney had an aptitude for science and math and a quiet dream of becoming a doctor, she ended up choosing an alternate road — and using an alternate aptitude — in business.
However, in the late 1980s, Forney found herself at a career crossroads… and reexamining her childhood dream. It was a case of now or never. She applied and was admitted to Emory University’s School of Medicine and graduated with a medical degree in 1996.
“I was a late starter,” says Forney, who completed her residency in San Francisco before returning to Atlanta to practice dermatology in 2000. A lot of people don’t have the opportunity to start a new career in mid-life. I was fortunate.”
The business of medicine
Forney acknowledges that her former career in business has been very helpful in her present occupation as a physician, especially when it comes to making a practice run efficiently.
“The biggest challenge for a doctor is running a business,” she says. “We must ask questions like, ‘How can I deal with government restrictions and the amounts that insurance companies will allow us to earn, while still delivering excellent care to our patients?’ I spend a lot of time thinking about how to do things well in my practice. And it helps to view them through business glasses.”
Quality of patient care and patient satisfaction are crucial to the success of a practice, as is addressing the needs and desires of the current patient base, Forney notes. Right now, that patient base includes a growing number of baby boomers.
“Care and support of mid-life patients is a large part of the dermatology practice these days. Luckily, I’m a baby boomer fighting aging, myself,” she says. “These patients are coming to dermatologists for medical and surgical solutions for health problems such as psoriasis or skin cancer. But they’re also very interested in cosmetic treatments such as Botox, “fillers,” hair removal and skin care products.”
Forney and her colleagues at Dermatology Affiliates make it a point to stay abreast of the latest medical advances in dermatology, both surgical and nonsurgical.
“For example, in the world of skin cancer, there is a desire to find ways to treat skin cancers non-surgically. In the past eight years or so, several alternatives to surgery such as creams and light treatments have become available,” Forney notes. “I think we’ll see many more nonsurgical treatments in the near future.”
There is also a growing demand for laser procedures, not just for hair removal but also for treating sun-damaged skin. Dermatology Affiliates has a Fraxel Dual Wave Laser, which employs a new wavelength to resurface skin.
“The Fraxel Dual Wave is a notable advance,” says Forney. “But we hope that the need for it will, one day, become extinct, simply because people are more knowledgeable about their skin and the sun, and are taking better care of themselves.”
The MAA and the “10-90” Rule
Like most everyone else these days, physicians find themselves squeezed financially and they have to make tough decisions about where their dollars are getting the most return. Sometimes, this means cutting back on memberships in specialty associations.
Forney, who currently serves as President of the Medical Association of Atlanta (MAA), says that it’s important for associations to offer services that are of real value to members.
“There are so many organizations in which doctors already have to participate, so the MAA is constantly looking at ways to increase services and resources that will benefit members and make membership attractive,” she says.
Forney also points out that strides made by the MAA are beneficial not only to its members, but to all Atlanta area physicians. She calls it the “10-90” Rule.
“Let’s say that about 10 percent of the Atlanta physician population are members of the MAA. Those 10 percent are carrying the other 90 percent,” she explains. “The members who are active participants are achieving results that benefit all doctors — yet all doctors don’t have to belong. Can you imagine the huge difference it would make if the other 90 percent would join the association and add their support?”
Forney is passionate about the MAA and encourages all area physicians to join — even if they can’t participate actively — because there is strength in numbers.
“Just because you’re not participating doesn’t mean you shouldn’t join,” she explains. “One of the main benefits to membership is being part of your local physician community. Being a part of it — even if all you do is read the association newsletter — makes you aware of what your community is doing and what’s going on in your profession, including political activity.”
The association has provided significant opinion and guidance in times of crisis and uncertainty for the health of the region’s citizens. A prime example of this is the struggling Grady Health System. Grady is the only level I trauma center within 100 miles of metro Atlanta, and also provides important emergency services for burn, asthma, sickle cell and stroke patients, among others.
“If Grady went under, it would affect all of us. Grady absorbs the lion’s share of treatment for trauma victims in Georgia. Patients with nowhere else to turn go to Grady. A huge number of physicians have trained at Grady. The MAA has been very vocal about the importance of Grady to the entire community,” Forney states. “Even if we can’t entirely change the situation, we can at least talk about it. It’s our responsibility to create awareness and gain support for issues like this.”
The MAA gives a unified voice to the Atlanta physician’s voice, especially when it comes to legislation. Considering the fact that Georgia’s Governor and other elected officials often turn to the MAA for expert advice and opinions, having a strong and active membership is critical, says Forney.
“What happens to physicians affects our patients. If doctors don’t have a role in setting healthcare policy at all levels, government will control it all. People would be shocked at the impact our government has on doctors’ lives,” she states. “As physicians, we should be able to shape the system for the better in terms of the health of America. We need to be at the table with an organized voice. We can’t be there as individuals; we have to be there as a group.”
For Rutledge Forney, it’s obvious that a second career in medicine was a natural progression from her earlier calling to the business world. She has been able to channel the best of both skill sets, plus a passion for making the healthcare world a better place, into one perfect occupation. Sometimes, a dream deferred evolves into a dream realized.
Rutledge Forney, M.D., is board certified in medical, surgical and cosmetic dermatology. Her practice, Dermatology Affiliates, has two locations — one in Buckhead and the other in East Cobb. For more information, log on to dermatologyaffiliates.com.
The influence and significance of Shepherd Center reach well beyond Atlanta, the state of Georgia and even the United States. Shepherd Center draws patients who need treatment for spinal cord injuries, acquired brain injuries, multiple sclerosis, chronic pain and other neurological conditions from every state in the country, plus as many as 30 foreign countries.
Shepherd Center actually had a relatively “small” introduction. In 1973, Alana and Harold Shepherd’s 22-year-old son James sustained a spinal cord injury in a surfing accident while on vacation in Rio de Janeiro. After spending several weeks in a Brazilian hospital struggling to survive, the Shepherds brought James back to the United States, where he spent another six months at a rehabilitation facility in Colorado. There, he regained his ability to walk while using a cane and a leg brace.
Frustrated that James couldn’t receive this kind of specialized care anywhere in the Southeast, the Shepherds were not content to stop after his recovery. With his parents’ support, James founded Shepherd Center in 1975 to bring high-quality spinal cord injury care closer to home. At that time, the center was simply a six-bed unit that operated out of leased space in an Atlanta hospital.
From those humble beginnings, Shepherd Center has grown from six beds to 120, has roughly 1,300 employees and is recognized around the world as a rehabilitation treatment facility for catastrophic illnesses and injuries, and as an advocate for people with disabilities. The hospital runs at nearly full capacity all of the time, with a census of more than 100 patients, almost daily.
Medical Director Donald Peck Leslie, M.D., notes that Shepherd Center receives a large number of referrals from other facilities, particularly because it can handle highly complex cases.
“For example, Grady Memorial Hospital here in Atlanta is our No. 1 source of referrals. As a Level 1 trauma center, they often have patients who must be transferred to a treatment facility with an intensive care unit,” he explains. “We have our own ICU here at Shepherd, which most rehabilitation hospitals do not have. We’re in touch with the trauma surgeons at Grady almost daily.”
Referrals have increasingly come from other states and countries. Dr. Leslie adds that this is the first year Shepherd Center surpassed the percentage of patients being referred in state by referrals from other states and countries. He attributes this trend to Shepherd Center’s active presence in the international health care arena.
“We belong to a number of international organizations and make presentations at conferences and meetings around the world, and we’ve been asked to help other facilities put together their own rehabilitation programs,” Dr. Leslie states. “But the reality is that most countries don’t have the resources and expertise needed to start a rehabilitation treatment facility.”
Dr. Leslie attributes much of Shepherd Center’s phenomenal growth to the community support it has received since its inception.
“We’ve been fortunate to have such an incredible response from the Atlanta community and beyond,” he says. “Of the 14 model system spinal cord injury treatment centers around the U.S., we’re the largest, and the only one that is not part of a bigger medical center.”
Not Just For Rehabilitation Anymore
Shepherd Center is not simply a rehabilitation hospital. It’s also a world-renowned center for neurorehabilitation research, focused on developing, refining and evaluating new treatments, drugs, surgical techniques, diagnostic tools and various therapy interventions. Its clinical studies on spinal cord injury, brain injury, multiple sclerosis and neuromuscular disorders are conducted in collaboration with leading experts at other hospitals, research centers, medical schools and universities around the world.
One of Shepherd Center’s premier areas of study occurs in its Spinal Cord Injury Research Program. Directed by Keith Tansey, M.D., Ph.D., this program is especially interested in restorative neurological research and conducts studies that address the recovery of function in residual, reorganized or regenerated neural circuitry in patients with spinal cord injury. Shepherd Center’s Spinal Cord Injury Research Program is developing a human studies laboratory called the Spinal Cord Injury Lab (SCIL) to expand its capacity to translate discoveries made in basic scientific research to studies in people with spinal cord injury.
“I’ve encouraged Shepherd to step closer to the basic science research bench. There’s a narrow pipeline between the basic scientists and clinical research,” says Dr. Tansey, noting that nearby universities – Emory, Georgia Tech and the University of Georgia – are all doing interesting research on the spinal cord in animals. “Right now, there are a lot of things that work successfully in the animal lab, and we’d love to know if they work on humans. I’d like to know not only if an idea is going to work, but also how it’s going to work.”
To find that out, human subjects must participate in lab studies. “Someone has to study the first 10 to 15 human patients in a lab setting as if they were doing a basic science experiment with lab rats, where they look with great precision at the biology,” Dr. Tansey explains. “In the case of spinal cord injury, by doing this type of research, we can learn how changing the specifics, such as with locomotor therapy, can increase patients’ ability to realize greater functional recovery.”
Shepherd Center’s spinal cord injury research using human subjects will help provide an understanding of how the nervous system responds in any predictable way, answering questions about whether patients improve by applying a given therapy, by reductions or increases in that therapy, by using a combination of drugs or electrical stimulation and therapy, and more.
SCIL’s first area of study will be neural plasticity, Dr. Tansey notes, and it will involve electrophysiological techniques to determine how a patient’s muscles and reflexes are working, in addition to using robotic devices to measure improvements in strength and movements.
“We want to look at interventions that can regulate and help the patient recover, and what changes can be made in rehabilitation therapy to make it more effective. The use of robotics will be particularly helpful in providing us with information,” he says. “We’ll also be able to change individual parameters using robotics, which can help determine how to get the patient to the next level of recovery. It’s evidence-based evolution of therapy.”
In addition to spinal cord injury research, Shepherd Center has programs that conduct research in acquired brain injury, multiple sclerosis, assistive technology and more. Shepherd Center’s research also works to improve the effectiveness and cost-effectiveness of clinical services, as well as to document the long-term effectiveness and benefits of rehabilitation to improve patient outcomes.
Shepherd Center employs some of the latest specialized technologies to help its patients regain function they’ve lost. One such technology, the NeuRx Diaphragmatic Pacing System (DPS), provides crucial assistance to patients who’ve suffered phrenic nerve damage due to spinal cord injury. Because the phrenic nerve gives neurological capability to the diaphragm, damage to the nerve can render a patient unable to breathe without assistance from a ventilator.
Shepherd Center Associate Medical Director Brock Bowman, M.D., along with physicians at other facilities, such as Piedmont Hospital and the Cleveland Clinic, led clinical trials on the pacing system. Since the pacing system received FDA approval in the summer of 2008, 10 Shepherd Center patients have undergone the procedure to implant the NeuRx DPS.
According to Shepherd Center consulting surgeon Saeid Khansarinia, M.D., the NeuRx DPS can make a significant and dramatic improvement, especially in the lives of quadriplegic patients. “The DPS system frees our quadriplegic patients from the constraints and limitations of the ventilator, thus allowing them the closest thing to natural breathing,” he explains. “They have the freedom to move with less equipment, they experience the return of natural speech, taste and sense of smell, and there is less risk of lung infection.”
The system works by surgically placing a pacemaker onto the actual diaphragmatic muscle to assist the patient in breathing on his or her own; a small computer device regulates the pacing. For some people, this means being able to take a break from being on a ventilator; for others, it may mean being able to wean off a ventilator permanently.
“The pacing system has helped people with Lou Gehrig’s disease, who get worse very slowly over time, as well as people with spinal cord injuries,” Dr. Leslie says. “It’s giving hope to patients who want to get off the ventilator, at least some of the time. We’re fortunate to be able to help them, since so many people who suffer this kind of nerve injury don’t even make it to the hospital.”
Shepherd Center’s therapeutic treatments are as advanced as its technologies. Many of its patients are benefiting from a program called “Beyond Therapy,” in which they have completed traditional rehabilitation protocol, but can opt to continue a nontraditional therapy of electrical stimulation of musculature that focuses on one particular aspect of rehabilitation, such as walking. The electrical stimulation is delivered to the selected muscles via a Swiss-engineered piece of equipment called the Lokomat, which Shepherd Center has two of. The Lokomat is a system of external orthoses that straps onto the patient. The robotic orthoses have motors in the hip and knee joints to move the patient’s legs. It can also give feedback as to how much the patient is working with the machine.
“It’s amazing to see people who haven’t walked for days, weeks or even months, do some limited ambulation,” Dr. Leslie says, “and the Lokomat can help patients who simply need muscle strengthening. The more they use it, the more close to normal range of motion they can get.”
As its research program develops and its staff develops even higher levels of expertise, Shepherd Center will continue to help its patients achieve better outcomes and become more independent, fulfilling its pledge to provide a high quality and complete continuum of care for those in need of rehabilitation.
To learn more about Shepherd Center, its patient care, its research programs and more, log on towww.shepherd.organdshepherdTV.org. Patients interested in participating in clinical research studies can even sign up online.
In Georgia alone, according to figures from the Georgia Cancer Coalition, every year between 1992 and 2002, some 5,200 lung cancers were reported. During that same period, 4,000 Georgians died from lung cancer.
“The problem with lung cancer is that it grows in asymptomatic patients,” says William Mayfield, M.D., Chief Surgical Officer for WellStar Health System and a board-certified thoracic and cardiovascular surgeon at Marietta’s WellStar Kennestone Hospital. “By the time you have symptoms, it’s generally too late to cure. The best way to cure lung cancer is to detect it in its earliest stages and take it out.”
Sounds simple enough, but there’s one catch – and it’s a pretty big one. To date, there is no widely accepted method for early detection.
“We have screening exams for breast cancer and for cervical cancer in women, but lung cancer kills more women than breast cancer and cervical cancer combined,” Dr. Mayfield says. “We have screening for colon cancer and prostate cancer in men, but lung cancer kills more men than colon cancer, prostate cancer and pancreatic cancer combined. So what’s the problem – why aren’t we screening for the deadliest disease?”
To address the situation, Dr. Mayfield, a pioneer in video-assisted cardiac and thoracic surgery who’s practiced for 20 years, has joined forces with an international effort to determine if low-dose radiation computed tomography chest images (i.e., CT scans) are, indeed, the most effective means to detect lung cancer early on.
Dr. Mayfield serves as principal investigator for WellStar Health System’s participation in I-ELCAP, the International Early Lung Cancer Action Program. Founded in 1991 by a group of physicians at Cornell University, the study, Dr. Mayfield says, “aims to determine whether or not low-dose CT scanning saves lives by early detection. That’s what we’re trying to do – determine if low-dose CT scanning saves lives from lung cancer.”
Because they involve low-level radiation, Dr. Mayfield says CT scans are drawing some fire as a safe means of early detection. In response, he points to another once-controversial procedure that’s now the leading means of early detection for breast cancer – mammography.
“The criticisms of CT scanning for lung cancer are the same as the criticisms were of mammography for breast cancer screening 15 years ago,” he says. “Mammography had to undergo 10 years of testing and scrutiny and statistical analysis before it was determined that it really was saving women’s lives with breast cancer.”
Stage 1A adenocarcinoma caught early through screening
Local Impact
WellStar Health System, which operates five hospitals in the Metro Atlanta area along with numerous physicians’ group sites, is enrolling participants for the study, which it refers to simply as the Lung Cancer Screening Study. Anyone 40 and over, who either is a current smoker, has smoked for at least one year or lived for at least 10 years with a smoker, is eligible.
For agreeing to take part, Dr. Mayfield says, participants receive a considerable discount on the cost of the CT scan. The $270 fee for each test can be covered with funds from a flexible spending account. “This is a huge discount over what you would be required to pay for a CT scan and an interpretation under any medical plan,” he says.
Plus, unless a patient has an abnormality such as a mass, discovered via chest X-ray or has a clinical condition such as pneumonia or some probable cause, such as coughing up blood, insurance companies tend to deny coverage for a CT scan.
“The study is entirely voluntary,” says Vickie Beckler, R.N., WellStar Health System’s lung cancer screening coordinator. “The one thing we do ask each participant is that they commit to coming back for at least one follow-up. However, to be effective for screening for early stage lung cancer, you really need more than one follow-up. We encourage annual screenings. For most people that first follow up will be 12 months, but for a few it could be sooner – it just depends on what we find on the initial screening exam.”
As for length of participation, there is no set-in-stone cutoff date for the study to end. “The study is actually just set for accruals until Cornell determines that the database proves statistically that the detection and the workup of these patients saves lives,” Dr. Mayfield says.
Participants don’t have to be WellStar Health System patients, either. The study is open to anyone willing to drive to one of four screening sites: WellStar Cobb Hospital in Austell, WellStar Douglas Hospital in Douglasville, WellStar Kennestone Hospital in Marietta and WellStar Paulding Hospital in Dallas.
Beckler’s job is to explain the study to participants and assist with completion of enrollment documents, then stay with them throughout the procedure. She also reports the findings back to the participant, after the scans have been analyzed by study subinvestigators, who are pulmonologists at WellStar Health System’s STAT (Specialty Teams and Treatment) Clinic, a cancer treatment facility located on the WellStar Kennestone campus.
“We have a multidisciplinary team of lung specialists that works with us on the study, including dedicated radiologists and pulmonologists,” Beckler says.
It usually takes about a week to mail the test results to participants, but Beckler goes over them verbally prior to that. And if cancer is suspected, Dr. Mayfield meets with participants and discusses their options with them. After that, it’s up to the patient and his or her primary care physician to come up with a treatment plan. WellStar Health System patients are likely to be treated at the STAT Multidisciplinary Lung Cancer Clinic, where Beckler works closely with a nurse navigator who is assigned to each patient to monitor that person’s progress.
It is important to note that the I-ELCAP Lung Cancer Screening program is a part of the larger continuum of care program for lung cancer at WellStar Health System. That continuum of care includes Smoking Cessation Clinics, the I-ELCAP Study, the STAT Multi- Disciplinary Clinic and other advanced medical services. Those advanced services for lung cancer include CyberKnife radiation therapy for appropriately selected patients, video-assisted thoracic surgery for cancer surgery and clinical trials available through affiliated medical oncologists.
Positive Side Effects In addition to gathering data to prove the CT scan’s effectiveness, Dr. Mayfield says, “We are picking up very early stage lung cancers in people who are completely asymptomatic, who had no idea they had lung cancer, who would very likely have died of their disease. It truly is changing people’s lives.”The study is also helping to uncover other abnormalities. “We also do look at incidental data,” Dr. Mayfield says. “We have found thyroid cancers, coronary artery disease and some aortic aneurysms. Those are incidental findings; the patients are treated for those by the appropriate practitioners, but it is not the focus of the study.”
So far, about 450 people have participated in the study at WellStar Health System, Dr. Mayfield says, in addition to some 45,000 international participants at other study sites, which are located at universities and medical centers throughout the United States and abroad.
“It’s not really about numbers,” Beckler says, “it’s about quality and doing what’s right for the patient. There’s so much that goes into each case. We have a very thorough program. Much of our program’s success is due to the dedicated physician leadership team heading the study.”
Indeed, WellStar Health System has been, if not exactly keeping the study under wraps, not shouting it from the rooftops, either. The reason: Response from within the WellStar Health System itself since participation began in June 2008 has been strong. Also, word of mouth is proving an outstanding method of getting the message across.
“Through word of mouth, this has developed a life of its own,” Dr. Mayfield says. “For example, we’ll have a patient who comes in and gets scanned and she feels it’s so important that she then calls her sister to get her scanned, and then she and her sister get their husbands to come in and get scanned. It’s been somewhat of a viral syndrome that markets itself.”
And getting the word out to women is key. “Nothing in the medical world moves until you get women involved,” Dr. Mayfield says. “Women are going out there and getting their mammograms and their pap smears. I want them to know that if they are a smoker or former smoker, they’re at higher risk of dying from lung cancer than they are breast or cervical cancer. We have to get women around this issue because it’s the most lethal cancer of all for them.”
Dr. Mayfield is more than aware that it will take action on the part of many individuals to make a difference. “We have a chance to change the course of this disease in our local population,” he says, “and it’s really a matter of awareness. That means asking our primary care doctors to talk to their patients that smoke or were former smokers, and realize that they really, really are at risk of lung cancer – and that we’ll never answer the question about early detection unless we all pull together and support this type of study.”
It has been a big year for Yasir Yesuf and his family. Yasir, a native of Ethiopia, just celebrated his first birthday thanks in large part to the extremely dedicated and talented medical professionals at Children's Healthcare of Atlanta (CHOA). In December of 2008, Yasir became the first pediatric patient in the state of Georgia to receive the EXCOR Pediatric ventricular assist device, better known as the Berlin Heart.
In the past, families of infants and children who were critically ill with debilitating cardiac problems and awaiting transplantation had very few treatment options. The best physicians could hope for was to keep their patients managed with medications or place them on extracorporeal membrane oxygenation (ECMO) and hope that a donor heart would become available sooner rather than later. Unfortunately, many children continued to deteriorate and by the time a heart became available, they were often too ill with multiple organ failure to have a successful outcome. Pediatric cardiologists and surgeons now have a lifeline to offer these children that is very promising in terms of keeping these kids healthy enough to have a fighting chance at a good transplantation outcome - the Berlin Heart.
The EXCOR Pediatric ventricular assist device is manufactured by Berlin Heart. The European-based company provides a variety of ventricular assist devices (VDAs) for use in the adult population and the first-ever pediatric device for infants and children. The pediatric device is offered with three different kinds of cannulas, made of high-quality medical silicon, to address anatomical differences in patients. The EXCOR Pediatric blood pump has five volume choices ranging from 10 ml to 60 ml depending on a patient's weight and body surface. The entire device is powered by a laptop computer installed in the Ikus driving unit that powers the pump. The EXCOR Pediatric unit has triple redundancy to the system to ensure patient safety and device reliability.
The inflow cannula is implanted into the left ventricle with the outflow being attached to the aorta. Essentially, the Berlin Heart is acting as the left ventricle. An additional device may be implanted in to the right ventricle if full support is necessary.
Although VADs are commonly used in adult patient populations, there have not been any devices available for children under the age of 3 or infants. The Berlin Heart offers the first real hope for many pediatric patients. "The Berlin Heart allows us to support the circulation of critically ill children awaiting heart transplantation - especially infants - more safely than with previously used devices," said Dr. Kirk Kanter, Chief of Cardiothoracic Surgery at Children's Sibley Heart Center and professor of cardiothoracic surgery at Emory University School of Medicine. "With the Berlin Heart, we can get children waiting for a transplant off the ventilator, walking around and eating - making them better candidates for heart transplantation when a suitable donor does become available."
The Berlin Heart has not yet been fully approved by the Food and Drug Administration (FDA); however, CHOA has been granted permission to use the device as a bridge to transplant on a case-by-case compassionate-use basis. Compassionate use is a term used to define the provision of experimental medications or treatments prior to final FDA approval. According to Dr. Brian Kogon, pediatric cardiothoracic surgeon at CHOA Sibley Heart Center and Chief of Adult Congenital Cardiothoracic Surgery and assistant professor at Emory University School of Medicine, patients are considered for the Berlin Heart only when all other options have been exhausted and it is determined that the heart will not recover of its own accord. At that point, the steps to implant a Berlin Heart device take place. "When we have patients who present with cardiomyopathy, we go through many steps to support the heart in hopes that they will recover using everything from medication to mechanical support," said Dr. Kogon.
ECMO, a heart-lung bypass, has been the standard in supporting critically ill children awaiting heart transplantation. The patient must be sedated with a paralytic agent to be placed on the ECMO device. The rate of complications is significant with patients on ECMO. "This device is much more invasive, with less than half of the patients surviving until transplantation is available," said Dr. William Mahle, Medical Director of Clinical Research and pediatric cardiologist at CHOA Sibley Heart Center. Dr. Mahle is also associate professor of pediatrics at Emory University School of Medicine. "Of the patients that are on ECMO, there is an 80% increased chance that they will reject their donor heart when it is implanted as well as an 80% increased chance of death within the first five years," said Dr. Mahle.
The Berlin Heart only supports the heart rather than the heart and lungs and therefore the patient can be awake and ambulatory unlike ECMO. Patients can also be on the device for an extended period of time if necessary. Heart failure causes children to lose weight or not to gain weight at all. "The Berlin Heart can prevent this from happening and therefore these children are much healthier going into the transplant," said Dr. Mahle.
The EXCOR Pediatric VAD is similar to other devices in that a pneumatic device is used that squeezes with each heart beat. "The Berlin Heart is much smaller, which is why it is ideal for pediatric patients," said Dr. Mahle. "The challenge is that there is an increased risk of clotting within the pump, which is why heparin or warfarin is given to address these issues." While the internal device is not reused, the external pumping device that powers the Berlin Heart is rotated among hospitals. The demand for the device is ever increasing and there is a wait, although according to the staff at CHOA, the manufacturer has been extremely responsive in expediting delivery. "We enjoy having the Berlin Heart as an option because there are few choices in children who are small," said Dr. Kogon. In fact, at the time of this interview, Dr. Kogon was preparing to do a potential Berlin Heart procedure the following day on a 1-month-old female whose heart was not showing signs of improvement. To date, more than 200 Berlin Heart procedures have been performed in the United States.
The pediatric cardiac surgeons led by Dr. Kanter rely heavily on the team approach to make the process of implanting the Berlin Heart a success. There are four heart transplant coordinators, critical care nursing staff and cardiac intensive care support staff. The research team deals with all of the FDA paperwork and is responsible for getting the device to the surgical team. Anesthesia, surgical attendings and residents, perfusionists, blood bank staff and post-op care are all involved, along with many others. "It is important to have all of these areas of expertise to make the chances of success high," said Dr. Kogon. "The Berlin Heart opens up the repertoire of what we can do and the services we can provide to our patients," said Dr. Mahle. Dr. Mahle reports that 18% of infants have died while waiting for a donor heart. He has high hopes that the Berlin Heart will greatly reduce this number in the future.
Dr. Mahle offers the following advice to other physicians and centers who are considering pursuing the Berlin Heart procedure as an option. "You must have a team in place before you get the first patient because of the detailed process. Anticoagulants and management of blood products are essential and you must have a lot of experience with ventricular-assist devices to be successful." Dr. Mahle also recommends that the nursing staff be well trained in the post-op care of the patients receiving the Berlin Heart and in fact the manufacturer recommends that the same person be in charge of post-op wound care. Although the cost of this cutting-edge procedure can exceed $100,000, CHOA supports its use and Dr. Mahle reports that most major insurers are supportive of the device and therefore this should not be a barrier to treatment.
The physicians and staff at CHOA are very proud of the fact that the Berlin Heart procedure is now an option for their most medically fragile pediatric patients. "This device has allowed a child who would not have survived for transplantation to have an option," said Dr. Kogon. "We have a center that has the personnel who can do this kind of complex procedure." The significance of CHOA offering this type of surgical option is crucial for the state of Georgia and the region. "Children's has always offered comprehensive cardiac care, which means a child should never have to leave the state for the care they need," said Dr. Mahle. "We are strongly committed to this."
The Berlin Heart is just one real-life example of how technology is improving daily and offering new options to patients who once had no options. "This extraordinary possibility has allowed these kids to survive and live a normal life," said Dr. Kogon. Dr. Mahle agrees and went on to say, "The Berlin Heart has gone from being a novelty to an important tool for treating critically ill children." The devoted team at CHOA helped young Yasir have a new chance at life with the use of the Berlin Heart and a successful heart transplant. The hope at CHOA is that many more children will live to see many more birthdayswith use of this dynamic technology in the hands of a skilled and talented team.
