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Archive for July, 2015

Pulmonology

Friday, July 31st, 2015

By Helen K. Kelley

Pulmonology, an internal medicine subspecialty, is concerned with diseases of the lungs and bronchial tubes and often involves evaluation of the upper respiratory tract (nose, pharynx and throat) as well as the heart. Interventional pulmonology is a relatively new field in pulmonary medicine that uses endoscopy and other tools to diagnose and treat conditions in the lungs and chest.

 

Flexible bronchoscopy useful in diagnostics, therapeutic applications

William Kenny, MD“Fiber optic bronchoscopy did its part to change the world in late ’60s and early ’70s,” says William R. Kenny, M.D., of Piedmont Physicians Pulmonary of Atlanta. “The technology kept evolving, resulting in flexible bronchoscopes with ultrasound probes that can transmit data in real-time today. Now, we are able to see through the wall of the trachea or bronchus, which is especially helpful to examine and needle biopsy lymph nodes or masses that are suspicious for cancer or infection.”

This technique, called endobronchial ultrasound (EBUS), uses ultrasound along with bronchoscopy to visualize the airway wall and structures adjacent to it. It offers physicians a means of making more accurate diagnoses as well as performing therapeutic procedures in patients with certain lung diseases and conditions. According to Dr. Kenny, having this improved visualization can lead to a more accurate diagnosis and help determine the best course of treatment. It can also assist in more accurate staging of cancers.

“The electromagnetic navigation (ENB) procedure makes it possible to perform diagnostics on nodules in the lungs that were previously not accessible,” says Dr. Kenny. “The superDimension™ navigation system creates a 3-D CT scan of the nodule, plotting its exact location in the lung. Then, the system guides a steerable catheter that can biopsy a tumor distally in the lung. This is a big improvement over the use of interventional radiology, with less risk of pneumothorax.”

Dr. Kenny adds that flexible bronchoscopy is helpful in performing therapeutic applications via various instruments that can be passed through the bronchoscope.

“Most of the scopes have channels that can accommodate brushes and biopsy forceps, which obtain cytology and histology specimens,” he says. “We can also use scopes for procedures such as balloon dilation of a constricted bronchus, cauterization of a mass or loop cautery to remove a polyp, obtaining uncontaminated fluid samples, or removing a foreign body that the patient accidentally aspirated.”

The advancing technology continues to provide pulmonologists with enhanced capabilities.

“The scopes are getting better all the time,” Dr. Kenny says. “For example, today we have digitized images. Everything I’m looking at on the screen is a digital image that can be copied, printed or magnified. That’s an advantage.”

 

Interventional pulmonology plays important role in multidisciplinary approach

Rabih Bechara, MDInterventional pulmonology (IP) is a discipline that involves the use of less invasive endoscopic procedures in the diagnosis and potential therapy of patients with malignant and non-malignant diseases involving the lung and the chest cavity.

According to Rabih Bechara, M.D., FCCP, Chief of Interventional Pulmonology, Pulmonary & Critical Care Medicine at Cancer Treatment Centers of America, because of its numerous applications, IP plays an important role in a multidisciplinary approach to treating patients with lung diseases.

“Patients have better outcomes when a team of physicians cares for them; importantly, each member of that team brings his or her special set of skills to the table,” says Dr. Bechara, who is also Professor of Medicine at Georgia Regents University School of Medicine. “For example, a patient with cancer may be receiving treatment from a radiation oncologist. Another team member, the interventional pulmonologist, can assist the radiation oncologist by placing markers in the patient’s tumor to help guide the delivery of radiation in a more accurate and safe manner.”

Interventional pulmonologists perform therapeutic procedures in patients with malignant or benign airway obstruction. In addition, they perform advanced endoscopic procedures that enable thoracic surgeons to localize small lung nodules prior to surgery. The latter results in less tissue loss during resection. Additionally, IP has taken on an increasingly important role in the staging of lung cancer, a crucial step in the management of patients with lung malignancies.

“Earlier diagnosis is always best, but appropriate staging is equally important in directing what type of therapy is needed,” says Dr. Bechara. “In the past, we relied on more traditional invasive surgical procedures to stage patients with nodes in the chest area. But today, endoscopic ultrasonography provides high specificity and sensitivity, is much less invasive and is very reliable in the staging process.”

Endoscopy can also prove helpful for cancer patients who have become resistant to their current treatment.

“We know that cancer cells sometimes mutate, therefore becoming resistant to treatment. So if a patient isn’t responding to therapy, something may have changed within their cancer cells,” Dr. Bechara says. “The latest endoscopic techniques allow the interventional pulmonologist to re-biopsy these patients in order to acquire new tissue, which can be examined to see if the cancer cells have mutated. Then, the multidisciplinary team can create a new treatment plan, tailored to the patient, based on the specific characteristics of his or her cancer cells.”

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Howard Silverboard, MD

Friday, July 31st, 2015

Howard Silverboard, MDHoward Silverboard, M.D., is medical director of thoracic oncology at the Northside Hospital Cancer Institute. Dr. Silverboard joined the Pulmonary and Critical Care of Atlanta team in 2003. He is board certified by the American Board of Internal Medicine in pulmonary, critical care and internal medicine.

Dr. Silveboard wrote Molecular Genomics and the Advancement of Lung Cancer Therapy for ATLANTA Medicine, Cancer, Vol. 86, No. 2

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Molecular Genomics and the Advancement of Lung Cancer Therapy

Friday, July 31st, 2015

By Dr. Howard Silverboard

 

Contemporary lung cancer therapy requires an understanding of the molecular composition and biologic activity of individual tumor cells. Advances in laboratory technique, characterization of biomarkers and the identification of genetic alterations have facilitated a transformation in the diagnosis and management of patients with lung cancer in 2015. Therefore, a lung tumor diagnosed today requires both accurate pathologic subtyping and genomic analysis to determine the optimal therapy.

Genomic testing of lung tumors has become a new standard of care now that genetic factors have been identified in the development of virtually all cancers. Lung adenocarcinomas harboring epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements are among the best understood. Consequently, “small molecule” therapy targeting the respective oncogenic pathways related to these target molecules have been developed and continue to be investigated.

Erlotinib and crizotinib respectively, are examples of such medications that are classified as tyrosine kinase inhibitors (TKIs). By targeting these specific molecules, investigators aim to preferentially kill malignant cells while preserving normal tissues. From a patient’s perspective, the enhanced sensitivity toward tumor cells translates to fewer side effects and improved survival when compared to more traditional systemic chemotherapy.

However, despite the recent progress of targeted therapies, these medications are not curative, and disease relapse consistently occurs through acquired resistance. Another major barrier to the advancement of lung cancer therapy includes the high level of heterogeneity inherent to lung cancer genomics. Whereas a handful of identifiable markers are associated with a majority of breast cancers, our current understanding of lung cancer encompasses only about 20 percent of such tumors.

The variety of oncogenic alterations present in lung cancer appears to be far more numerous, and therefore much work remains. Many more new molecular targets will need to be identified, and ultimately clinical trials will need to be performed. Northside Hospital (NSH) seeks to become a leader in lung cancer related research through an array of public and private partnerships.

In association with the Addario Lung Cancer Medical Institute (ALCMI) in San Carlo, Calif., and its sister organization, The Bonnie J. Addario Lung Cancer Foundation (BJALCF), patients may participate in studies aimed to identify new molecular targets and advance our understanding of lung cancer genomics. In a collaborative manner, ALCMI aims to identify unique populations of lung cancer patients with unique molecular targets by collecting proteomic, genomic, molecular and clinical data across a multitude of institutions and oncology networks. The ultimate goal is development of more novel and targeted therapies to further impact the lives of lung cancer patients.

The Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial (ALCHEMIST) is another important study open for patient enrollment at NSH. This study is sponsored by the National Cancer Institute (NCI) and similarly seeks to analyze tumor specimens and identify genetic targets. In addition, ALCHEMIST investigators will study the efficacy of genetic-based drugs among surgically resected patients with EGFR or ALK positive lung cancer in reducing recurrence among patients at earlier stages of disease.

Patients with squamous cell carcinoma (SCCA) of the lung demonstrate a genetically distinct morphology when compared to adenocarcinoma and its related mutations described above. Furthermore, delineation of molecular genotyping and the development of appropriate targeted therapy aimed at SCCA has lagged. Subsequently, the NCI,NSH and the cancer research cooperative group SWOG Cancer Research, among others, are collaborating to enroll patients in the Lung-MAP clinical trial.
The Lung-MAP clinical trial will test the efficacy of five investigational drugs. The study aims to build on the demonstrated progress against adenocarcinomas of the lung by matching treatment regimens against specific mutations found among patients with SCCA. Patients with SCCA who have failed first-line conventional therapies are eligible for enrollment.

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Tenet and WellStar Start Discussions About Potential Acquisition

Friday, July 31st, 2015

Tenet Healthcare and WellStar released the following comment.

“Tenet Healthcare and WellStar Health System have begun exclusive, non-binding discussions about a potential sale of Tenet’s Atlanta-area hospitals and associated facilities to WellStar. This is to ensure that these hospitals and facilities are best-positioned to meet the needs of their communities and continue delivering high-quality healthcare for many years to come. While these discussions continue, we will maintain our standard policy of not commenting on development activities until we have something definitive to announce.”

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2015 GSO/HNS Annual Summer Meeting

Thursday, July 23rd, 2015

July 23-26, 2015, Sonesta Resort, Hilton Head Island, SC. For more information, visit The Georgia Society of Otolaryngology/Head & Neck Surgery 

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WellStar Opens Outpatient Surgery Center at East Cobb Health Park

Monday, July 20th, 2015

WellStar recently opened an Outpatient Surgery Center at the WellStar East Cobb Health Park, providing a convenient location for surgeries that do not require a hospital stay.

“Since WellStar first opened a health park in Acworth three years ago, our community has embraced the health park concept and the convenience it provides,” said Candice Saunders, president & CEO of WellStar Health System. “Over the next decade, we expect to see outpatient services continue to grow. WellStar will continue to meet the healthcare needs of our communities through innovative solutions and world-class healthcare.”

The surgery center includes 20 private, prep/recovery rooms, three operating room suites and three procedure rooms. The center also provides onsite pathology support, a private patient discharge elevator and covered pick-up area separate from the Health Park’s main entrance.

The 162,000-square-foot WellStar East Cobb Health Park opened in September 2014, bringing primary and specialty physician offices together with comprehensive diagnostics, laboratory services, rehabilitation therapy, urgent care, a retail pharmacy, and now, an Outpatient Surgery Center.

The health park’s physician mix includes family physicians, internal medicine, pediatrics and OB/GYN services. Specialty areas include cardiology, pulmonology, ENT, neurosurgery, pain management, chiropractic care, vascular surgery, general surgery, allergy/asthma, endocrinology, urology and orthopedics. Rheumatology will be added in August.

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New Study Aimed at Diminishing Phantom Pain Suffered by Amputees

Monday, July 20th, 2015

A new clinical trial conducted by Emory Saint Joseph’s Hospital interventional radiologist J. David Prologo, MD is studying a minimally invasive investigational treatment known as cryoablation therapy, hoped to help relieve symptoms in amputees with residual and phantom limb pain.

As the principal investigator of the study, Prologo is using CT imaging guidance to place a probe near the nerve responsible for the residual phantom pain. Once the probe is precisely placed, the temperature is dropped for 25 minutes to create an ablation zone, and the signals the nerve was previously carrying are shut down.

The outpatient procedure takes approximately one hour, and some patients have reported significantly decreased pain and improved function.

Norma Jean Robinson, one of the first patients to complete the cryoablation therapy at Emory Saint Joseph’s, has seen her pain drop to a minimum after the amputation of her leg six months ago. “On a scale of one to 10, my pain had reached the highest level — a 10,” she says. “Having this procedure has dramatically changed the quality of my life.”

For more information about this study, contact the Emory University School of Medicine, Division of Interventional Radiology and Image Guided Medicine at 404-509-9132, 404-520-3233 or john.david.prologo@emory.edu.

Below is the video featuring the patient Norma Jean Robinson.

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WellStar Kennestone Hospital Opens Inpatient Pediatric Unit

Monday, July 20th, 2015

WellStar Kennestone Hospital opened a new inpatient pediatric unit earlier this month. Previously, Cobb County did not have an inpatient pediatric unit, forcing families to leave their community to receive hospital-based care.

The 4,700 sq. ft. unit is staffed 24/7 exclusively by pediatric-trained caregivers including a team of pediatric hospitalists who remain on duty around the clock, pediatric nurses, pediatric respiratory therapists and a dedicated pediatric pharmacist.

“We took great effort to ensure that we were getting the ‘best of the best’ in pediatric care to serve on this unit,” said Avril Beckford, M.D., WellStar chief pediatric officer. “The child is at the center of everything we do. For the children of our community, we recruited the cream of the crop in pediatrics.”

Lead Hospitalist Timothy Horton, M.D. comes to WellStar from Children’s Hospital of Los Angeles and Carrie Nalisnick, M.D., assistant lead hospitalist, joins the team from St. Louis Children’s Hospital. Additionally physicians Manpreet Dhillon, M.D. and Blaine Crosslan, M.D. will join the team. In all, 28 pediatric team members will work in the unit including nurses, respiratory therapists and support services.

The space features 12 private patient rooms for overnight hospital stays. Patients will benefit from a central monitoring system in each exam room, enhanced security, ultraviolet filters for infection control, and all pediatric-specific and pediatric friendly equipment.

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Drs. DeLurgio and Halkos Collaborate on New Atrial Fibrillation Procedure

Monday, July 20th, 2015

Emory Saint Joseph’s Hospital is offering a new minimally invasive procedure to treat patients suffering from longstanding persistent atrial fibrillation (AF) called the Convergent procedure. The Convergent combines the expertise of a cardiac electrophysiologist and a cardiothoracic surgeon, and involves the ablation of the inside and outside of the heart to restore regular rhythm to the heart.

At Emory Saint Joseph’s, David DeLurgio, MD, director of electrophysiology, and cardiothoracic surgeon Michael Halkos, MD, are working collaboratively to provide the best outcome for AF patients. AF patients experience irregular heartbeat, fatigue and shortness of breath, and in addition to these symptoms, are also at increased risk of stroke or heart failure. This persistent condition has been historically difficult to treat, and the Convergent procedure is a new option for patients where traditional medical therapies have failed, such as medication or a standard endocardial ablation.

“Many patients have experienced less than optimal results with medical treatment of their atrial fibrillation and have been told they have to live with the symptoms it produces. The Convergent procedure offers hope for maintenance of a normal rhythm and improved quality of life with a minimally invasive approach,” says DeLurgio.

The Convergent procedure is performed under anesthesia and takes approximately four to six hours. The goal is to restore a patient’s normal heart rhythm through ablation. A two-step process is used to block the abnormal electrical signals that cause an irregular heartbeat. First, the cardiothoracic surgeon makes a small incision in the abdomen to gain access to the outside of the heart through the diaphragm. The surgeon then uses epicardial ablation to produce lesions (scar tissue) on the heart in order to block these signals.

Next, the electrophysiologist enters the inside of the heart through a vein in the leg to ablate the abnormal signals that occur in and around the pulmonary veins.

“This hybrid procedure combines the best of what the electrophysiologist and the surgeon have to offer” says Halkos. “With the surgical portion, the surgeon ablates the back of the left atrium, typically the most challenging portion for the electrophysiologist. The electrophysiologist can use advanced mapping techniques to ensure successful ablation, and reliably ablate the pulmonary veins and other specific lesion sets. Although long-term data does not yet exist, we are optimistic that this will provide relief for a significant proportion of patients with symptomatic atrial fibrillation.” After the procedure, patients typically spend two nights in the hospital and should plan to rest at home for one week, DeLurgio adds.

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Bryce Gartland, MD Named CEO of Emory University Hospital

Sunday, July 19th, 2015

Bryce Gartland, MD, chief operating officer (COO) at Emory University Hospital, has been named chief executive officer (CEO) of the hospital, as current CEO Robert Bachman steps down to move into a new hospital role, effective August 14.

Gartland will also serve as CEO for two other entities that fall under Emory University Hospital: Emory University Orthopaedics & Spine Hospital and Emory University Hospital at Wesley Woods.

Gartland joined Emory as a physician in 2005 practicing in hospital medicine. He has held several leadership roles in his specialty area and in hospital operations. In 2012, Gartland assumed the position of COO at Emory University Hospital. Since then, he has played key roles in numerous accomplishments, including the hospital’s stellar University HealthSystem Consortium (UHC) rankings for quality and safety achievements, Magnet accreditation for nursing excellence and the successful treatment of four patients diagnosed with Ebola virus disease.

In Bachman’s new role, he will serve as the executive director for expansion/renovation at Emory University Hospital. His responsibilities will include overseeing the completion of the new $400 million, nine-story hospital wing currently under construction on Clifton Road, as well as other renovations planned within the hospital.

Bachman has spent his career at Emory serving in a number of leadership positions. Since 2000, Bachman has provided exceptional leadership and vision for Emory University Hospital, most recently as CEO.

“Moving Bryce into the CEO role is a natural progression and a testament to the strength of our succession planning program,” says Dane Peterson, Emory Healthcare Hospital Group President. “I have full confidence that Emory University Hospital will continue to excel with Bryce at the helm of an already strong leadership team. While we will miss Bob’s leadership skills, we know his talents will be instrumental as we continue to expand and grow at the hospital.”

Last year, Gartland was named one of Modern Healthcare’s Up & Comers for 2014. The annual list showcases 12 health care professionals, ages 40 and under, who have shown leadership qualities and business acumen that stand out among their peers, colleagues and hospital administrators.

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