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Archive for April, 2015

GMGMA Annual Conference April 2015

Sunday, April 26th, 2015

April 26, 2015, The Grove Park Inn, Asheville, North Carolina. For more information, visit Georgia Medical Group Management Association 

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2015 Walk Now for Autism Speaks

Sunday, April 26th, 2015

April 26, 2015, Atlantic Station: Pinnacle Lot, Atlanta. For more information, visit Autism Speaks

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GMGMA April 2015 Board Meeting

Saturday, April 25th, 2015

April 25, 2015, Asheville, North Carolina. For more information, visit Georgia Medical Group Management Association

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Walk MS: Georgia 2015

Saturday, April 25th, 2015

April 25, 2015, Piedmont Park, Atlanta. For more information, visit National Multiple Sclerosis Society Walk MS 

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When Less is More: Single-Site Robotic Surgery Offers Improvements for Surgeon and Patient

Wednesday, April 22nd, 2015

By Helen K. Kelley

From ATLANTA Medicine, Vol. 85, No. 4

robotic surgeryAs minimally invasive surgery becomes a more common and popular option for patients undergoing certain medical procedures, the technology used to perform these procedures is constantly evolving. New techniques allow doctors to perform both minor and complex surgeries as outpatient procedures, with only a few small incisions – a great improvement over open surgeries that formerly required much larger incisions, along with lengthier hospital stays and recovery times for patients.

Robotic laparoscopic surgery, performed with the assistance of technology such as the da Vinci® Surgical System, is now considered the gold standard of treatment for many medical conditions. Robotic surgery has reduced the number of open surgeries for common operations by enhancing the surgeon’s capabilities in performing minimally invasive procedures.

Improving patient and surgeon experience

Introduced in the late 1990s, the da Vinci® Surgical System continues to undergo enhancements that are changing and improving the surgical experience for both surgeon and patient.

Recent improvements have created a more efficient surgical environment for the OR staff. During the procedure, the surgeon sits at a console that offers a 3-D high-definition image of the patient – while viewing that image, the surgeon then uses controls to manipulate robotic arms with tools to perform the surgery.

In earlier years, the robot was permanently docked at the beginning of a surgery. If the patient required repositioning, surgical staff then had to stop and also reposition the robot. Today’s da Vinci’s® systems allow the surgeon and OR staff to move around to different regions of the patient’s anatomy without undocking the robot. Also, the system’s camera is no longer stationary as in previous generations of the technology – it can now be moved and placed on any one of the robotic arms at any time.

Additionally, new tools are giving surgeons even better precision for certain procedures, with improved results for the patient.

For example, laparoscopic cholecystectomy (laparoscopic gallbladder removal) – a big advancement over what was previously an open surgery that meant several days in the hospital for the patient – is an outpatient procedure that involves four approximately inch-long incisions in the abdomen. Now, a recent technological improvement has made an even less invasive procedure possible. Single-Site™ Instrumentation is a new operating platform attached to the da Vinci® Si™ Surgical System that allows surgeons to remove the gallbladder through a single incision.

Patrick Kenney, D.O., a board-certified general surgeon at North Fulton Hospital in Roswell, first observed the da Vinci® Surgical System more than 10 years ago. Though impressed with its ability to increase precision in laparoscopic surgeries, he knew the system was somewhat limited in its applications at the time. Later, when the manufacturer added some helpful tools, Kenney decided to undergo training to begin using the system.

“In the first few years, the system only worked well for certain operations, such as gynecological procedures,” he says. “But when da Vinci developed improved technologies and added devices to seal blood vessels and staple, it opened up new applicability.”

Dr. Kenney, who began performing laparoscopic procedures using the da Vinci® Si™ Surgical System a little over two years ago, says the newest development is making some procedures, such as gallbladder removal, less invasive than ever before.

“The single-site platform features improved instrumentation that allows surgeons to perform certain procedures with only one incision,” he explains. “So now, a gallbladder removal can be done by making one small incision through the belly button – and the patient has less pain and scarring.”

The single-incision technique also offers surgeons much-improved control over the instrumentation, according to Dr. Kenney.

“I have better visualization and precision when I perform these procedures,” he states. “I feel that it leads to safer surgeries and improved outcomes for the patients, like less blood loss, less pain, fewer complications and faster recovery time.”

robotic surgery 2Where’s the scar?

Clara Parry, a patient of Dr. Kenney’s, says she was pleased to have the option of single-site surgery. Parry, who ended up in the emergency room during a recent gall bladder attack, was examined by Dr. Kenney and offered the choice of a four-incision removal or a single incision.

“The single incision just sounded like the right way to go. One incision versus four seems more logical,” she says. “And the recovery was really not bad at all.”

Parry underwent the procedure on a Thursday. By the following Monday, she was already getting out of the house to do errands.

“I’d never had surgery before. But this was not at all what I was expecting. I woke up in the recovery room and asked if it was over!” she recalls. “I was a little uncomfortable, but I didn’t have any nausea and needed very little pain medication. I was able to shower right away and it felt good to get up and walk.”

Parry and Kenney agree that the single incision has an additional benefit.

“Belly buttons hide scars wonderfully!” Dr. Kenney says.

“There’s just a small scar,” adds Parry. “You’d have to really be looking for it to see it.”

About Single-Port Laparoscopy

Single-port laparoscopy (SPL), or single-incision laparoscopic surgery, is a minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient’s navel. Unlike a traditional multi-port laparoscopic approach, SPL leaves only a single scar.

SPL has been used to perform many types of surgery, including:

• adjustable gastric banding

• appendectomy

• cholecystectomy

• colectomy

• hernia repair

• hysterectomy

• sleeve gastrectomy

• nephrectomy

• sacrocolpopexy

Benefits include less postoperative pain, less blood loss, faster recovery time and better cosmetic results.

However, there may also be complications from SPL, such as significant postoperative pain, injury to organs, bleeding, infection, incisional hernia, intestinal adhesions and scarring.

The Whole Team

The da Vinci Si System is an integration of advanced technologies, including:

Firefly™ Fluorescence Imaging. The Firefly Fluorescence Imaging Vision System enables surgeons to use a special video camera and glowing dye to view blood flowing in vessels, and tissue or bile moving through ducts during minimally invasive surgical procedures. It is intended to provide real-time endoscopic visible and near-infrared fluorescence imaging. Firefly enables minimally invasive surgery using standard endoscopic visible light as well as visual assessment of vessels, blood flow and related tissue perfusion, and at least one of the major extrahepatic bile ducts (cystic duct, common bile duct and common hepatic duct), using near infrared imaging.

Single-Site®. Single-Site’s transumbilical entry enables a virtually scarless surgery. Instruments and camera cross within the Single-Site port and use remote center technology to avoid cannula collisions, arm interferences and port-site movement. Single-Site is commercially available for laparoscopic cholecystectomy, hysterectomy and salpingo-oophorectomy for benign conditions only.

Skills Simulator™. Skills Simulator’s built-in metrics enable users to assess skills, receive real-time feedback and track progress. Administrative tools let users structure their own curriculum to fit with other learning activities in their institution. The open architecture of the system software allows for the future development and incorporation of additional practice modules.

Advanced Instrumentation. The Si System enables mechanical function of advanced instruments including EndoWrist One Vessel Sealer and EndoWrist Stapler 45.

 

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Mary Ransbotham, RN

Wednesday, April 22nd, 2015

Mary Ransbotham, RNMary Ransbotham is a Registered Nurse with more than 25 years of experience specializing in diabetes self management education and management. As a Certified Diabetes Educator, Mary has driven program development and implementation of many educational offerings in the field of diabetes for the community, hospital patients and staff. She is the manager of the Piedmont Atlanta Hospital Diabetes Resource Center, where she manages inpatient and outpatient diabetes services in a 500+ bed urban hospital. She also serves as team leader of the Diabetes Clinical Orders Team, which is responsible for identifying and responding to hospital needs and developing evidence-based standing orders, pathways and protocols for inpatient diabetes care. She has served on the American Diabetes Association Leadership Council, Atlanta Region and numerous other local and regional diabetes conference planning boards, and leadership roles in the Greater Atlanta Diabetes Association of Diabetes Educators.

Ransbotham wrote Care Critical: Diabetes Self-Management Education for ATLANTA Medicine, Diabetes, Vol. 85, No. 4

 

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Care Critical: Diabetes Self-Management Education

Wednesday, April 22nd, 2015

By Mary Ransbotham, RN

From ATLANTA Medicine, Vol. 85, No. 4

Mary Ransbotham, RN

Mary Ransbotham

Diabetes is a chronic, progressive disease that requires ongoing complex medical management, and the physician’s role extends well beyond glycemic management. A large body of evidence exists to support a range of interventions to improve diabetes outcomes, including Diabetes Education. Diabetes Education includes Diabetes Self-Management Education (DSME), Diabetes Self-Management Support (DSMS) and Medical Nutrition Therapy (MNT).

According to the American Diabetes Association’s (ADA) Clinical Practice Recommendations, “DSME is an essential element of diabetes care.” This fact has been recognized for more than 15 years by the Centers for Medicare and Medicaid Services as evidenced by their DSME reimbursement structure. Medicare reimburses for 10 hours of DSME and three hours of MNT during the first year of diagnosis or the first year under Medicare, if the education is delivered by an education center recognized by the ADA as meeting the National Standards for Diabetes Patient Education Programs.

Diabetes Self-Management Education (DSME)

The mission of diabetes self-management education and support (DSME/DSMS) and Medical Nutrition Therapy (MNT) is to help individuals with diabetes acquire the knowledge, skills, attitudes and behaviors needed to optimize both their self-management skills and their quality of life. As the field of diabetes education has developed over the last several decades, the profession has evolved from skill based to helping people with diabetes (PWD) gain the knowledge of behavior change that will help them live with an overall sense of improved well-being. Diabetes Education now includes knowledge and skill acquisition as well as problem-solving, goal setting and coping skills.

Preferably, education will be provided by Certified Diabetes Educators (CDEs). CDEs are experientially and educationally prepared to provide education, support and guidance through the healthcare system.

Comprehensive self-management education is best delivered as a combination of group classes and individual counseling. Groups provide support, socialization, the opportunity to learn from others and to garner support from their peers. Because diabetes management in integral to daily life, it is in some ways a family disease. Family members and significant others are encouraged to participate in all aspect of diabetes education.

In 2014, a “one-size fits all” approach to diabetes education is recognized as ineffective and will likely lead to a discouraged, unengaged patient. There are core elements of education, but each topic will be modified to the individual. Each patient must recognize the importance and relevance to their own life to improve the likelihood of adherence.

Below are the seven components of diabetes self-management as defined by the American Association of Diabetes Educators.

  1. Heathy Eating
  2. Being Active
  3. Monitoring
  4. Taking Medications
  5. Problem Solving
  6. Healthy Coping
  7. Reducing Risk

Each of these topics is addressed with the individual at some point in the education process. How and when they are addressed is based on a thorough assessment by the CDE.

Oftentimes, in the outpatient setting, it is more appropriate to begin with problem solving or healthy coping to first prepare the patient for the unavoidable lifestyle changes that lie ahead. Knowledge of healthy eating and being active is of little use to the patient who is unable or unwilling to adapt his/her current lifestyle to incorporate this new knowledge. If a patient is newly diagnosed and insulin therapy is being initiated, monitoring and medication rise to the top of the list for immediate education, even before the patient has had time to developany coping skills for dealing with diabetes.

Diabetes Self-Management Support

DSME is effective and necessary for initial and ongoing diabetes care, but it is taking place in a healthcare setting. Actual self-management takes place in the patient’s home and community. Initial improvements in metabolic control have been found to diminish after about six months.

According to the National Standards for Diabetes Self-Management Education and Support, it is incumbent upon the diabetes educator to help the patient develop a plan for ongoing support. There are many types of support (behavioral, educational, psychological, etc.) and a variety of resources available.

The patient is likely to find support through membership in the American Diabetes Association, ongoing participation in follow-up programs, online communities and local community events as well as from their PCP.

Medical Nutrition Therapy

Nutrition therapy recommendations for people with diabetes have changed dramatically over the last 20 years. Gone are the days of confusing exchange lists, the “one size fits all” approach and the elimination of entire food groups. Today’s nutrition focuses on moving patients from a place of unhealthy eating to healthy eating. Meal planning takes into account the individuals’ metabolic goals, current treatment plan, likes and dislikes, their usual eating patterns, comorbidities, ethnicity, literacy and numeracy, income, support system, availability of healthy food and willingness to change. Based on the individual’s need, a number of approaches may by be used.

According to the latest Nutrition Therapy Guidelines published in 2013, the goal of MNT is “to promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion size, in order to improve overall health. …”

Highlights of the guidelines:

  • There is no one meal plan or eating pattern that works universally for all people living with diabetes, nor is there an optimal mix of macronutrients.
  • A variety of eating patterns are acceptable for the management of diabetes.
  • Evidence is inconclusive for an ideal amount of carbohydrate intake.
  • For people with DM and diabetic kidney disease (either micro or macroalbuminuria), reducing the amount of protein below usual intake is not recommended because it doesn’t alter glycemic measure, cardiovascular risk or the course of GFR decline.

The person living with diabetes must make multiple decisions each day that affect their diabetes management and consequently, their lives. These decisions are difficult even with DSME; without it, these uninformed decisions are likely to be far less than optimal.

Multiple studies have found that DSME is associated with improved diabetes knowledge, self-care behaviors, clinical outcomes and quality of life. In spite of its proven success, less than 50 percent of people living with diabetes have ever received any formal diabetes education. Findings from a study published in 2009 assessing the value of diabetes education indicate that diabetes education is associated with increased use of primary and preventive services and lower use of acute, inpatient hospital services.

Diabetes Education is associated with higher compliance rates for nearly all Healthcare Effectiveness Data and Information Set (HEDIS) measures. Conclusions reached by the studies are that the collaboration between diabetes educators and physicians yield positive clinical quality and cost savings. The cost savings are entirely related to reduced inpatient costs. Conversely, outpatient costs are higher due to increased utilization of primary care and pharmacy services. Over time, however, patients who use diabetes education services are more likely to receive recommended care and have lower average costs and better clinical outcomes.

To locate a Recognized Diabetes Education program near you, consult the American Diabetes Association’s website at www.diabetes.org.

References

  1. Nutrition Therapy Recommendations for the Management of Adults With Diabetes, Position Statement , Clinical Practice Recommendations, Diabetes Care, 37, Suppl1, January 2014.
  2. National Standards for Diabetes Self- Management Education and Support, Position Statement, Clinical Practice Recommendations, Diabetes Care, 37, Suppl1, January 2014.
  3. The Art and Science of Diabetes Self-Management Education, AADE, 2006.
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LLCMGMA Meeting

Monday, April 20th, 2015

April 20, 2015, Lanier Park Campus, Gainesville, Ga. For more information, visit Georgia Medical Group Management Association

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AMGMA April Meeting

Thursday, April 16th, 2015

April 16, 2015, Atlanta. For more information, visit Atlanta Medical Group Management Association

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AAO Mid-Year Forum 2015

Wednesday, April 15th, 2015

April 15-18, 2015, Renaissance Downtown Hotel, Washington D.C. For more information, visit Georgia Society of Ophthalmology

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