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Archive for October, 2012

Emory/Grady Psychologist Honored With 2012 Beckman Award

Wednesday, October 31st, 2012

Nadine J. Kaslow, PhD, ABPP, professor and vice-chair in the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine, is the recipient of the prestigious 2012 Elizabeth Hurlock Beckman Award.

Founded in honor of Dr. Beckman, an educator and pioneer in the field of psychology, the award recognizes the influence of extraordinary professors on the future of their students.
Kaslow, who also serves as chief psychologist for the Grady Health System, was one of 22 professors from universities nationwide who received a cash award this year. Beckman awards are given to those who have inspired their students to create real-world success.

Kaslow is a member of Rosalynn Carter’s Mental Health Advisory Board and is a nationally recognized expert in suicide, intimate partner violence and child maltreatment, depression in children and adolescents, posttraumatic stress disorder, and education and training in psychology.

Her accomplishments include a Presidential Citation from the APA for her efforts to assist displaced interns and postdoctoral fellows in the aftermath of Hurricane Katrina. In 2012, she received a Doctorate of Humane Letters from Pepperdine University. Additionally, Kaslow is President-Elect Designate of the American Psychological Association (APA), and a member of the APA Board of Directors. She is the recipient of multiple federal and foundation grants, has published over 270 articles, and serves as editor of the Journal of Family Psychology.

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Lab Tests Assist Rheumatologists in Making Correct, Cost-Effective Diagnoses

Tuesday, October 23rd, 2012

Many times as rheumatologists, we are asked about lab testing in patients with rheumatic problems. This article will mix some of the political, operational and mechanical issues within this topic. 

Most important above the entire lab testing is the history and physical examination.

The labs tests are a guide that helps define our patients, but the history and physical are the main guides to proper management.

The Centers for Medicare & Medicaid Services (CMS) took away the consultation code for specialists in January 2010. Nevertheless, it is careful examination and clinical evaluation that saves more in costs.

Now, on to a discussion of the lab tests available and how they may help confirm a diagnosis. There are five main tests used in the rheumatology field to help make a diagnosis:

1. Westergren Sedimentation Test: This simple test for inflammation, if done correctly and fresh and NOT sent to a central lab like QUEST, Solstas, or LabCorp, 
can give us a lot of information about the status of the patients and their rheumatic complaints. It is not specific for a diagnosis; in fact, it was originally developed in the 1930s as a pregnancy test because it would rise during pregnancy and then fall after delivery. Even then, in the 1930s, they knew that any delay in performing the test would lessen numerical final result.

In my office, we run fresh sed rates despite the fact that some of the insurance companies would not pay for the correct test. I am surprised the central labs have not made that clearer on their lab reports.

2. C Reactive Protein (CRP): This, too, is a simple test for inflammation. It is reported either as mg/dL or for high sensitivity mg/L. Therefore, it is about a 1:10 
difference. We look at this test to judge inflammation. Of interest in Rheumatoid Arthritis (RA), there is about a 30+ percent discordance in that some people will have the sedimentation rate elevated or the CRP elevated, and about two-thirds will have both elevated. They measure different things. The high sensitivity is used by some to look at cardiovascular risks. In our Rheumatoid Arthritis (RA) patients, it is already high, consistent with the increased cardiovascular disease associated with inflammatory disease. Patients with RA have a higher cardiovascular risk, and people with RA die up to 10 years earlier with cardiovascular disease compared to the general population.

Of note: some of our medications including methotrexate and the biological Tumor Necrosis Factor inhibitors are making a dent in this risk and improving cardiovascular risk in RA.

3. Rheumatoid Factor (RF): This is found in about 80 percent of people with Rheumatoid Arthritis (RA). It is not specific for RA and is the body’s response to a chronic inflammatory condition. The most common cause of elevation of the RF in the world is malaria. We use it in rheumatology to help validate the diagnosis of RA using criteria for classification of RA by the American College of Rheumatology Criteria. It can be elevated in chronic infections such as endocarditis, and as the endocarditis is cured with antibiotics the elevated RF can normalize.

4. Cyclic Citrullinated Protein (CCP): This test is used now to help us diagnose Rheumatoid Arthritis, and also to judge the severity of RA. Those with the genetic risk of RA have potentially a higher risk of developing RA if they have smoked and carry either a single or double HLA-DR shared epitope(SE) gene and are anti-CCP positive. If you have smoked, you are at greater risk of having more severe RA, and it may not respond as well to therapy. Unfortunately, stopping smoking does not seem to help. The presence of both a positive RF and a positive CCP indicates a risk for more severe RA no matter else. Rheumatologists often order both the RF and CCP in combination for diagnosis and prognosis.

5. Antinuclear Antibody (ANA):  This is a test indicating the presence in the body of an antibody against the nucleus of the cell. Everyone has a positive ANA, but people with lupus and other members of the connective tissue disease family have a higher positive ANA. This test, when positive, is one of the criteria for the diagnosis of Systemic Lupus Erythematosus. Its presence is not specific for lupus. In fact, a positive ANA can be seen in people who have no demonstrable disease.  A positive ANA can also be seen in allergic reactions, other connective tissue disease and certain types of autoimmune hepatitis. A Rheumatologist will help guide the patient to understanding why the test is positive and whether it suggests lupus or not.

There are pitfalls in interpreting the ANA test. A few years ago the central labs like Quest and LabCorp and others like the Mayo Clinic changed the technique for identifying the ANA using an enzyme linked test (ELISA test) rather than the classic immunofluorescence (IFA) test. This was changed because they could automate their testing process. Central labs have developed the multiplex automated screens to process the large volume of clinical specimens.

Tests using ELISAs and coated beads are not accurate ANA screening tests. The classic ANA immunofluorescent Assay(IFA) test is the gold standard for testing for the ANA, and it uses a biological system, usually mammalian cells, including a kidney cell, liver cell or now the Hep 2 cancer cell (with its large nucleus). HEP 2 cells have hundreds of antigens(proteins and nucleic acids) that are distributed in orderly domains in a tissue culture cell and thus can tests for hundreds of different types of these antinuclear antigens. 

The ELISA test only identifies about 12 or so antigens, and thus many people with lupus were not readily identified.

Multiplex ANAs have a good ability to detect specific antigens. The automated tests may have a dozen or so nuclear antigens coated on the walls in plastic plates or on beads. These tests are good and specific for the antigens tested but not for screening. Through the American College of Rheumatology ANA task force, this was reviewed and eventually a position paper was published. This went to the College of American Pathologists (CAP) (who certify the labs) and to the labs themselves and encouraged them to do the right thing. Quest now has the ANA by immunofluorescence as a standard test, and it’s easily found on its website. However, LabCorp still uses the ELISA test to screen for ANA, and it’s not readily apparent on its website that it has the IFA. The correct ANA test code to screen for ANA by immunofluorescence at QUEST is 249, LABCORP is 164947 and FANA for Solstas Lab Partners.

These are just a few of the tests in our field. After the appropriate evaluation, these tests are used to help guide the correct diagnosis and treatment in our patients. It is 
important to emphasize, despite the regulations of CMS to the contrary, that the most cost-effective diagnosis is the correct diagnosis. As rheumatologists we do this.

John A. Goldman, M.D., MACR, FACP, CCD, is chief of rheumatology at St. Joseph’s Hospital, active staff at Northside Hospital and president of The Medical Quarters, P.C. He is rheumatology medical director of the Atlanta Center for Clinical Research. Dr. Goldman is a former clinical professor of medicine at Emory University School of Medicine. Current and former chairman of the Southeast Committee on Rheumatologic Care Network, Southeast Regional Advisory Council and the ACR Committee on Rheumatologic Care.  


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Gwinnett Medical Center Hires Darrow to Oversee Graduate Medical Education

Tuesday, October 23rd, 2012

Gwinnett Medical Center (GMC) has hired Mark D. Darrow, MD, FACP, as director of its new graduate medical education program. By July 2014, GMC will offer graduate medical education (GME) through the establishment of residency programs in internal medicine and family medicine.

Dr. Darrow joined GMC from South East Area Health Education Center, a non-profit organization based in Wilmington, N.C., that provides medical training and education. He was also the Vice President for Graduate Medical Education at New Hanover Regional Medical Center in Wilmington.

GMC will provide rotations at both hospitals in Duluth and Lawrenceville and at a local family health center.

“The addition of these two primary care training programs will help alleviate the shortage of resident physicians in Georgia and produce more primary care physicians for the state of Georgia who currently ranks 45th in the nation for the number of primary care physicians per 100,000 population,” said Phil Wolfe, president and CEO of GMC.

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AMA and MAG Seek Showdown with Health Insurers Over Georgia’s New Prompt-Pay Law

Tuesday, October 23rd, 2012

The American Medical Association (AMA) and the Medical Association of Georgia (MAG) have taken initial steps to block the health insurance industry’s attempt to rollback Georgia’s strong protections against health insurers’ unfair business practices.

In a joint motion filed  in a Georgia federal court, AMA and MAG asked to intervene against America’s Health Insurance Plans (AHIP) and its legal challenge to Georgia’s Insurance Delivery Enhancement Act of 2011, which requires health insurance companies that provide third-party administrative services to pay medical bills in a timely manner.

“This case has national implications for resolving the regulatory void in which health insurers are unaccountable for chronically late payments when they serve as administrators for self-insured employers,” said AMA President Jeremy A. Lazarus, M.D. “Georgia has effectively closed that regulatory loophole, which helps physicians maintain a sustainable practice environment.”

“The fundamental fairness mandated by Georgia’s statute allows physicians to redirect their limited resources from battling to get the payments they’ve earned to caring for patients,” said MAG President Sandra Reed, M.D. “The AMA and MAG will not allow the insurance industry to undermine the state’s prompt-payment law and compromise on-time payments for the medical care that is provided to Georgia’s workers and their families who are covered by an employer-funded health plan.”

Most office-based physicians work in small medical practices with bills to pay at the end of the month. The attempt to weaken Georgia’s prompt-payment law comes as the state’s small physician practices struggle with the high costs of technology requirements, excessive insurance red tape and a broken medical liability system.

“Holding health insurers accountable for on-time payment gives medical practices greater budget certainty and helps Georgia physicians keep their doors open and pay the salaries and benefits of more than 90,000 office employees,” said Dr. Reed. “The state’s prompt-payment law gives every Georgian additional peace of mind that they’ll have access to the physicians they need.”

“Georgia’s prompt-payment law is one of the most effective in the country, and the AMA and MAG are best positioned to defend the statute on behalf of physicians,” said Dr. Lazarus. “Continuing to provide our patients with the finest, most up-to-date care should not be jeopardized because insurance companies are delinquent in paying what they owe.”

The Litigation Center of the AMA and State Medical Societies, a legal action coalition consisting of the AMA and medical societies from each state plus the District of Columbia, is supporting the motion to intervene as defendants in the AHIP lawsuit.

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Emory Physicians Receive Grant to Develop Better Treatments for Transplant Recipients

Tuesday, October 23rd, 2012

A new $20 million grant to Emory University from the National Institute of Allergy and Infectious Diseases of the National Institutes of Health will allow physician/researchers to develop better treatments for organ transplant recipients that help avoid both organ rejection and drug toxicity. The  grant builds on more than 18 years of groundbreaking research by Emory scientists that already has significantly advanced the transplant field.

Outstanding short-term outcomes have been achieved in organ transplantation with the development of anti-rejection drug therapies. The approval in 2011 of the new transplant drug belatacept was a breakthrough based on years of research by Emory scientists and industry collaborators, providing a less toxic alternative to the standard calcineurin inhibitors like cyclosporine. Yet significant challenges remain for patients over the long term with organ rejection and drug toxicity that often leads to cardiovascular disease, infection or cancer.

“Despite tremendous advances in immune drug therapy, the fact remains that organ recipients still must take immunosuppressant drugs over their lifetimes,” says Chris Larsen, MD, PhD, executive director of the Emory Transplant Center and principal investigator of the new grant. “Improvement in these transplant drugs is still a critical need for avoiding acute and late-stage rejection. Ultimately, we want to improve overall health while reducing cost through improved outcomes with fewer drugs.”

In addition to Larsen, project leaders from the Emory Transplant Center will include Allan D. Kirk, MD, PhD, scientific director of the Emory Transplant Center and a Georgia Research Alliance Eminent Scholar; Leslie Kean, MD, PhD, Emory associate professor of pediatrics and director of the Pediatric Bone Marrow Transplant Division of the Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Stuart J. Knechtle, MD, surgical director of the liver transplant program at Emory Transplant Center and Children’s Healthcare of Atlanta, and Andrew Adams, MD, PhD, assistant professor of surgery.

“The most important feature of this award is its support for multiple investigators attacking the problems of immunosuppression from different but complementary angles,” says Kirk. “The team science approach is the best way to get results to our patients.”

Belatacept represents a new class of drugs called “co-stimulation blockers,” which inhibit one of two signals needed to generate an immune response by T cells. These drugs allow the body to accept transplanted organs while maintaining an immune response. Although belatacept avoids some of the toxicity of earlier transplant drugs, it is associated with higher rates of reversible acute rejection. And because it is a lifelong therapy, it still includes risks associated with a compromised immune system.

Several projects funded by the new grant will aim to develop more effective transplant drugs, adjuvant therapies combined with transplant drugs, and strategies to avoid immunosuppressant drugs altogether.

The Emory team has been a leader in chimerism-based immune tolerance induction, and is also expert in managing the potential risks of chimerism-induction as they apply to solid organ transplant. Kean leads the bone marrow project for this grant, which seeks to “fine-tune” chimerism-based strategies, to permit successful, safe tolerance-induction.

An additional project will develop strategies to overcome immune sensitization in patients who have had previous transplants, pregnancies or blood transfusions. These patients often are not candidates for transplant because of their increased risk of rejection.

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Innovative Breast Cancer Care Model Focuses on Rehabilitation and Exercise Therapy

Tuesday, October 23rd, 2012

Breast cancer is the most common cancer diagnosed in women. Treatments typically include surgery, chemotherapy, radiation, hormonal and other targeted drug therapies, which, coupled with early detection have increased five-year survival rates from 63 percent in the early 1960s to 90 percent today.

Growing evidence, however, suggests the physical effects of these breast cancer therapies can be taxing — causing pain, shoulder problems, fatigue, weight gain, weakness, lymphedema and osteoporosis.  The authors of a new breast cancer care model are hoping to change that.

The Prospective Surveillance Model (PSM) aims to promote monitoring for breast cancer related physical impairments during and after treatment.  The model was developed over the past year by a panel of diverse breast cancer experts in collaboration with advocacy groups and with funding support from the American Cancer Society and the Avon Foundation.

The model of rehabilitation is the first step toward greater awareness and recognition of the importance of incorporating rehabilitation services in breast cancer care and offers hope for improved quality of life among breast cancer survivors through rehabilitative therapy and exercise.

“The current model of medical care for women with breast cancer focuses on treatment of the disease, followed by intermittent surveillance to detect recurrence and any other problems patients report,” says Sheryl Gabram, Grady Health System surgeon-in-chief and director of the AVON Comprehensive Breast Center at Grady. “While both of these are, of course, extremely critical, most women may have subtle physical impairments as a result of their breast cancer treatment that impact function and quality of life. This new initiative is exciting because never before have breast cancer patients had a dedicated plan to guide functional rehabilitation, identify an individualized rehabilitation prescription, and promote healthy behaviors during and after cancer treatment.”

The PSM, which is still in the testing phase, promotes careful watch of common breast cancer-related physical impairments and functional limitations, through education, early detection, rehabilitation and exercise programs when impairments are identified. This proactive approach to functional assessment and rehabilitation occurs through periodic examinations and therapies both during and after cancer treatment.

“Our research suggests that if feasible, a pre-operative assessment followed by an early postoperative reassessment visit should take place 1-2 weeks after surgery, and upper-extremity range-of-motion exercises should be initiated within the first month after surgery,” says Gabram. “Being among the first centers to implement this innovative model affords an opportunity to study the true incidence of treatment-related impairments, the feasibility and logistics of implementation, its associated costs and the degree of patient benefit derived,” says Gabram.

Gabram and her team, which includes Jill Binkley, executive director of TurningPoint Women’s Healthcare, a not-for-profit women’s rehabilitation center, and Winifred Thompson, PhD, from the Emory’s Rollins School of Public Health, will test the prospective surveillance model by interviewing patients prior to surgery, asking them a set of standardized questions and measuring their arm function. This will be followed by a close surveillance plan and early intervention if any impairments are detected. Researchers will measure compliance to the model and identify barriers to early intervention. The pilot study is expected to open in November 2012.

“The Georgia Cancer Center for Excellence (GCCE) at Grady Health System is committed to treating the whole person, not just the cancer. Our intent is for patients to have the same quality of life after cancer treatment as before, including the ability to function independently,” says Gabram.

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BenchMark Physical Therapy Responds to Physician Demand by Opening 10 New Clinics

Tuesday, October 23rd, 2012

An aging boomer population and need for advanced physical therapy expertise in underserved areas are two reasons BenchMark Physical Therapy is adding an unprecedented number of new clinics throughout Georgia.  “We will open ten new clinics within the Georgia market in 2012,” according to Walt Porter, VP of Operations.

“Our physicians continue to ask for our help in serving their patients by opening clinics,” said Porter. He went on to say that while patients are willing to travel to appointments with specialty physicians, physical therapy should be convenient to work or home so that patients can more easily complete their plan of care.

“Studies show that when patients complete their plan of care, they are seven times more likely to return to work, use less healthcare benefits, and seven times less likely to have additional surgeries,” according to Porter.  “Clearly, the benefits of completing care are significant.”

According to Porter, the BenchMark difference is advanced certification in manual therapy, which is the fundamental clinical focus of the company. “We know that manual therapy is more effective for many diagnoses and that advanced training means that our patients will feel better and move better, faster,” he said, adding that the company evaluates patient progress and reports that their outcomes are significantly better than national averages.

New clinic locations include Buckhead, Canton, Ellijay, Lithonia, Locust Grove, Smyrna and Buford. This winter, the company will open three clinics in the greater Atlanta area.

 

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New Physicians Join WellStar

Sunday, October 21st, 2012

WellStar Medical Group recently welcomed the following physicians:

Adaeze C. Adigweme, M.D., MPH, has joined WellStar Medical Group, Hospitalists. He will be based at WellStar Kennestone Hospital. Dr. Adigweme received his bachelor’s degree in psychology from the University of Florida and his master’s degree from Emory University Rollins School of Public Health. He earned his medical degree from Emory University School of Medicine, where he also completed his residency in internal medicine. Dr. Adigweme is a member of the American College of Physicians.

Melissa Boekhaus, M.D., has joined WellStar Medical Group, Pediatric and Adolescent Center. Dr. Boekhaus received her bachelor’s degree in biology from Mercer University. She earned her medical degree from the Medical College of Georgia in Augusta and completed her residency in pediatrics at Emory University. Dr. Boekhaus is a member of the American Academy of Pediatrics.

Mark Quinn, M.D., has joined WellStar Medical Group, Radiation Oncology. Dr. Quinn received his bachelor’s degree in chemical engineering from the Georgia Institute of Technology in Atlanta. He earned his medical degree from the Medical College of Georgia in Augusta and completed his residency in radiation oncology at The Medical College of New York in Westchester, N.Y. He is a member of the American Society for Therapeutic Radiation and Oncology and is board certified in radiation oncology.

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MAG 2012 House of Delegates

Saturday, October 20th, 2012

October 20-21, 2012, Savannah. For more information, visit Medical Association of Georgia

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Guilherme Cantuaria, M.D., to Develop Clinical Trials for Cancer Patients

Monday, October 15th, 2012

Guilherme Cantuaria, MD, PhD, medical director of Northside Hospital’s NCI Community Cancer Centers Program (NCCCP), has been nominated by his peers to co-chair the Program’s national clinical trials subcommittee. This prestigious honor will allow Dr. Cantuaria to develop, initiate and conduct innovative clinical trials that will benefit patients both nationally and in Atlanta.

The NCCCP is a collaborative network of community hospitals working to: expand cancer research, enhance access to cancer care, and improve the quality of care for cancer patients served by community hospitals in urban, suburban and rural areas, with an emphasis on underserved populations. The network serves approximately 53,000 new cancer cases each year.

The clinical trials subcommittee aims to advance research into new cancer treatments by involving more patients in clinical trials, providing them the opportunity to benefit from the latest therapies before they are available to the general patient population.  NCCCP sites are building their capacities to offer earlier phase trials, which could reduce the need for patients to travel to urban, academic centers. Each site has a strong focus placed on reaching underserved populations, including minorities, the elderly, and those in both urban and rural communities.

Dr. Cantuaria’s role as Northside’s NCCCP medical director and principal investigator is a vital component that provides oversight of the activities of the hospital’s Cancer Institute, including clinical management, community outreach and disparities, clinical trials, information technology, biospecimen initiatives, quality of patient care, and survivorship and palliative care.

“It is a huge honor to have been elected by my peers to co-chair this clinical trials initiative,” said Dr. Cantuaria. “Through research, we can expand the understanding, diagnosis, treatment and prevention of disease, ensuring that patien ts have access to cutting-edge care, often in circumstances where conventional care fails them.”

Dr. Cantuaria is joined as co-chair of the clinical trials subcommittee by Edward Gorak, DO, MS, FACP, of Geisinger Health System in Danville, PA.  Dr. Cantuaria joined Northside in 2011 and is among the most distinguished and experienced robotic gynecologic cancer surgeons in the country, specializing in the da Vinci Surgical System.  He is an active member of several key professional societies including: the Society of Gynecologic Oncology, the International Gynecologic Cancer Society, the Brazilian Society of Obstetrics and Gynecology, and the American College of Obstetrics and Gynecology.

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