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Archive for November, 2015

Clinical Trial Demonstrates High Implant Success of World’s Smallest Pacemaker

Monday, November 30th, 2015

TPSBy Jennifer Johnson McEwen

A study presented this week at the 2015 American Heart Association Scientific Sessions, and simultaneously published in The New England Journal of Medicine, showed that the world’s smallest, minimally invasive cardiac pacemaker — the Micra Transcatheter Pacing System (TPS) — was successfully implanted in nearly all of the patients participating in the international clinical trial.

The single-arm trial enrolled 725 patients at 56 centers, including Emory. Results showed the Micra TPS, which is comparable in size to a large vitamin, was successfully implanted in nearly all patients – 99.2 percent (719 of 725) – and met its safety and effectiveness endpoints with wide margins.

Approximately 96 percent of patients experienced no major complications, which is significantly fewer – 51 percent fewer – than seen in patients with conventional pacing systems. Major complications included cardiac injuries (1.6 percent), complications at the groin site (0.7 percent) and pacing issues (0.3 percent).TPS

Emory Healthcare cardiologists were the first in Georgia, and among the first in the United States, to begin implanting the Micra TPS last year. Emory was the top enrolling U.S. site in the trial.

“We were pleased to participate in this important trial, as this will likely be the way pacemakers are implanted in the future,” says Emory site principle investigator Michael S. Lloyd, MD, associate professor of medicine, Emory University School of Medicine.

“The outstanding results are very encouraging and will allow us to continue to offer this novel device as a safe alternative to our patients.”

Lloyd, a cardiac electrophysiologist, implanted the first Micra TPS at Emory in April 2014 at Emory University Hospital. He says there are an estimated 3 million people living with pacemakers, and about 600,000 pacemakers are implanted in the world every year.

TPSDuring the procedure, the tiny device — approximately one-tenth the size of a conventional pacemaker — is delivered through a catheter inserted in the femoral vein to the inside of the heart. Once positioned, it securely attaches to the endocardial tissue of the heart wall and sends electrical pulses to the heart through electrode tips whenever it senses an abnormal heart rhythm.

Unlike conventional pacemakers, the Micra TPS does not require the use of wires, known as “leads.” These leads, threaded through blood vessels to connect to the heart, are sometimes the source of serious medical complications such as infection and vein injury.

Another important difference between the new device and traditional pacemakers is that implantation of the Micra TPS does not require a surgical incision and the creation of a “pocket” under the skin. Conventional pacemakers require a more invasive surgery.

“By not creating a pocket and implanting a rigid device directly below the skin, it eliminates another potential source of complications and any visible sign of the device,” says cardiologist Mikhael El Chami, MD, associate professor of medicine, who is also implanting the Micra TPS device at Emory.

Image Credit: Medtronic

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Emory Fights Early-Stage Breast Cancer with New One-Time Radiation Treatment

Monday, November 30th, 2015

Emory A new tool in the fight against breast cancer allows patients to undergo a one-time radiation treatment, directly in the cavity where the tumor has been removed, during surgery for early-stage breast cancer. A team of community and faculty doctors at Emory University Hospital Midtown is now treating patients with Intraoperative Radiation Therapy (IORT) during breast-conserving surgeries.

Emory University Hospital Midtown is one of three centers in Georgia to provide the treatment.

Targeted IORT is an individualized radiation treatment that delivers low-energy X-rays directly into the tumor bed at the time of surgery (immediately following a lumpectomy or partial mastectomy). During the procedure, the Zeiss INTRABEAM machine delivers the radiation dose through a spherical-shaped applicator, which is placed in the cavity to ensure direct contact with the targeted tissue. Radiation is delivered precisely to the area with the highest risk of tumor recurrence, while minimizing radiation to healthy tissue.

“IORT is a good option for patients undergoing breast-conservation surgeries because they can receive a single, targeted dose of radiation to the tumor bed during their surgical procedure, without radiating the entire breast,” says Karen Godette, MD, associate professor of radiation oncology, Emory University School of Medicine and medical director of the radiation oncology department at Emory University Hospital Midtown. “Clinical studies show that if patients are selected properly, IORT is just as good as standard radiation therapy after surgery, in terms of tumor recurrence.”

The one-time radiation treatment takes 20-45 minutes to deliver, depending on the size of the cavity. Most patients do not need supplemental radiation following IORT. The radiation treatment in the operating room also means no delay in receiving radiation. Standard radiation treatment usually begins four to six weeks after surgery to allow the surgical wound to heal.

“Proper selection of patients for this procedure is key,” says Rogsbert F. Phillips, MD, a community-based breast surgeon and Emory Healthcare Network physician at Emory University Hospital Midtown, who was instrumental in bringing this new therapy to the hospital. “The best candidates are usually women aged 50 and above who have early-stage breast cancer, or small tumors that have not spread to other areas of the body. This procedure is not appropriate for patients with aggressive breast cancers, such as triple-negative breast cancer or metastatic breast cancers.”

Emory Healthcare Network physician Yara Robertson, MD, who practices with Phillips, is also trained in the IORT treatment for breast cancer. Robertson emphasizes how important IORT is for patients who sometimes travel far distances to Emory University Hospital Midtown for breast cancer treatment.

IORT’s one-time treatment also costs less than traditional radiation treatments, which can last up to six weeks.

“Besides offering targeted radiation therapy to the tumor site with minimal side effects, the convenience factors should also be considered beneficial,” says Monica Rizzo, MD, associate professor of surgery at Emory, whose focus is on surgical oncology. “We are pleased to offer this treatment option to patients at Emory University Hospital Midtown, as we continue to promote the importance of finding and treating breast cancers early.”

Rizzo and Godette are members of Winship Cancer Institute of Emory University.

“IORT is a new modality for treating breast cancer, and it has proven to be as effective for the treatment of early breast cancer as compared to total breast radiation,” says Phillips. “More and more women are finding out about IORT and requesting it. The team of physicians at Emory University Hospital Midtown is proud to be a part of this cutting edge technology. We are grateful for our hospital leaders who supported this endeavor.”

INTRABEAM received FDA-approval in 1999, and is covered by most insurance companies.

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Northside Hospital Cancer Institute Receives Colonoscopy Grant

Sunday, November 29th, 2015

NorthsideNorthside Hospital Cancer Institute (NHCI) received a $3,597 grant from the Colon Cancer Coalition to help reduce the financial burden of colonoscopies for underserved patients in the Atlanta area.

Northside Hospital and Atlanta Gastroenterology Associates (AGA) will provide colon preparation kits more than 100 underserved patients at no cost. These patients will be identified through AGA’s ongoing Financial Assistance Program and by those who express financial need.

“Colonoscopies are one of the most powerful weapons for preventing colorectal cancer,” Dale Israel, disparities outreach coordinator for Northside Hospital Cancer Institute said. “They can prevent many cases by finding certain types of polyps before they have the chance to turn into cancer, furthermore, if found early, colorectal cancer is highly curable.”

According to the Colon Prep Center, kits typically cost $30 and may cost up to $35 for patients diagnosed with diabetes or other underlying conditions. The prep kit is an osmotic laxative use for cleansing the colon in preparation for a colonoscopy. The kits will either be available on site at the Colon Prep Center or ordered and shipped directly to the patients’ residence.

This grant is not the first that Northside has received for programs targeting the underserved. In July 2014, Northside was awarded a five-year grant by the National Cancer Institute Community Oncology Research Program (NCORP) to enhance cancer research in the community.

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Peripartum Cardiomyopathy

Wednesday, November 25th, 2015

By David W. Markham, M.D., MSc

Peripartum CardiomyopathyA 29-year-old woman presents two weeks after delivery of her second child complaining of lower extremity edema and dyspnea on exertion. She had mild dyspnea at the end of her first pregnancy two years ago, but she has had an uneventful second pregnancy. She has no other medical problems. The patient has a faint third heart sound (S3) on cardiac exam, basilar rales on lung exam, and 2+ peripheral edema. An echocardiogram shows an Ejection Fraction (EF) of 35 percent. The patient is admitted for diuresis in the setting of peripartum cardiomyopathy (PPCM). A few months pass, and her EF is now over 55 percent and normalized. She is asymptomatic. The patient asks about possibly becoming pregnant again. In this brief review, I will discuss a few of the questions surrounding this case.

What is PPCM?

PPCM is an important and often under-recognized cardiac disease of pregnancy. It is rare in the United States and has varied incidence around the world. When the disease occurs, it affects the mother, the children and the local community, especially in poor parts of the world. PPCM has been defined as a heart failure syndrome occurring in the last month of pregnancy or within five months of delivery, but some cases may manifest outside this time frame (1).

In the United States, PPCM has a reported incidence of approximately 1 in 3000 births (2). Studies from Deschapelles, Haiti, report one of the highest incidence rates in the world at approximately 1 in 300 births (3-4). Worldwide, the estimated number of women with PPCM could be as high as 72,500 cases a year if 145,000,000 babies are born each year and if there is an approximate incidence of 1 in 2,000 in childbearing women.

A variety of risk factors have been identified for PPCM (See Table 1), including history of hypertension, multigravid state, prolonged tocolysis, obesity, smoking and low socioeconomic status (5–9). Regarding race/ethnicity, the incidence of PPCM seems to be highest in women with an African or African-American background (10). Genetic factors likely play a role in PPCM, but specific links are not yet understood.

Peripartum CardiomyopathyThe etiology of PPCM remains unknown, but several hypotheses are being scrutinized. Inflammation has long been considered a possible etiology of PPCM, but data have not supported this hypothesis.

The viral hypothesis of PPCM has been considered. Viral genomic material has been discovered in cardiac biopsy specimens from PPCM patients, but the incidence is not different than controls (11). Immune activation may also be important in PPCM. For instance, various autoantibodies are found in some PPCM patients (12). The presence of fetal cells in the mother’s heart (microchimerism) also suggests a role for immune activation (13).

Micronutrient deficiency has also been proposed as a hypothesis because of the significant association of low socioeconomic status with PPCM. Hormonal imbalances are also a possible etiology in PPCM. Data in this area come from studies of the prolactin pathway (14-15). As such, bromocriptine, an inhibitor of prolactin, has been proposed as a treatment for PPCM, but the use of bromocriptine has not been widely accepted due to safety concerns and limited data. Another recently proposed mechanism involves abnormal angiogenesis (16). The variety of hypotheses regarding PPCM and supporting clinical data may suggest multiple pathways for development of the disease.

Peripartum CardiomyopathyHow Do We Diagnose and Treat PPCM?

Distinguishing PPCM is often difficult because of the high prevalence of edema and dyspnea during normal pregnancy. Practitioners must have a high degree of suspicion and be prepared to perform screening echocardiography. PPCM often goes undiagnosed or misdiagnosed. The typical symptoms of heart failure (HF) are often present in PPCM patients: edema, orthopnea, paroxysmal nocturnal dyspnea, dyspnea of exertion, exercise intolerance, cough and chest pain.

On the physical exam, patients may have the usual array of HF signs: elevated jugular venous pulsations, pulmonary rales, displaced apical pulse or S3 on cardiac exam, ascites or peripheral edema. Echocardiography is the cornerstone of PPCM diagnosis, particularly to assess left ventricular EF (typically < 45 percent) (17). Cardiac magnetic resonance imaging (MRI) can also be useful in the evaluation of PPCM patients.

All guideline-based recommendations for HF of other etiologies apply to the management of PPCM. Patients with HF due to PPCM are often initially treated with intravenous diuretics and vasodilatory agents. Inotropes may be necessary in some patients. Following stabilization, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, diuretics and digoxin make up the standard regimen for PPCM patients. Also, other vasodilatory agents may be added to the chronic HF regimen in some persistently symptomatic patients such as isosorbide and hydralazine.

Peripartum CardiomyopathyIt is important to note that patients diagnosed during the antepartum period often require early delivery. Beta-blockers are often titrated upward to obtain target doses recommended from clinical trials. ACE inhibitors and angiotensin II receptor blockers (ARBs) are not recommended for pregnant women because of the risk of fetal renal abnormalities. Aldosterone receptor antagonists should be avoided in the antepartum period. Diuretics should be used, in all instances, at the lowest possible dose to maintain a euvolemic state.

High incidence rates of left ventricular (LV) thrombi have been reported in PPCM patients, and stroke rates seem to be increased (18). This risk is likely complicated by the hypercoagulable state of pregnancy. Patients with severely reduced ejection fraction (EF<35 percent) should be considered for anticoagulation. During pregnancy, unfractionated heparin (UFH) or low molecular weight heparin may be used since they do not cross the placenta. After delivery, heparin or warfarin may be used since they are not secreted in the breast milk.

Duration of therapy for PPCM patients is controversial, and there is currently no consensus. If a patient’s left ventricular (LV) function normalizes, some practitioners recommend continuing guideline-based HF therapy for at least one year. One study has demonstrated, however, that some patients may have deterioration months or even years after diagnosis if medications are stopped (19-20). Similar results have been noted in the Haitian PPCM population (personal communication from Albert Schweitzer Hospital, Haiti). If the LV function remains depressed, drug therapy should be continued indefinitely.

It is important to note that short- and long-term outcomes in patients with PPCM are better than other types of non-ischemic cardiomyopathies. PPCM patients have a high rate of LV recovery. Overall, the risk of death is low, but some patients do progress to refractory HF and need cardiac mechanical support or cardiac transplantation (21-22).

What About Subsequent Pregnancy After PPCM?

Studies of subsequent pregnancy after PPCM consistently show higher risk in unrecovered (abnormal LVEF) vs. recovered (normal LVEF) patients. The risk of decreased LV function during a subsequent pregnancy for a recovered patient is 20-30 percent. The risk of decreased LV function during a subsequent pregnancy for an unrecovered patient is 50 percent. The risk of death with subsequent pregnancy in recovered vs. unrecovered patients is approximately 0-5 percent vs. 15-20 percent (23-24).

Some studies suggest that a stress echocardiography test (dobutamine or exercise) may be helpful in risk stratification (20). Patients who have a normal stress echocardiography result seem to have a favorable prognosis, while an abnormal result may suggest a higher risk with subsequent pregnancy. For PPCM patients who elect to have subsequent pregnancies, our practice has been to perform frequent echocardiography – as often as every 4-6 weeks – during pregnancy and after delivery.

Back to the Patient

In the case presented at the beginning of this article, the decision to become pregnant again is complicated and is not without some risk. It is perhaps favorable that this patient had complete recovery of LV function and is asymptomatic, but if she becomes pregnant again she will require close monitoring and follow up.

References

  1. Pearson Gd, V.J.R.S. and et al., Peripartum cardiomyopathy: National heart, lung, and blood institute and office of rare diseases (national institutes of health) workshop recommendations and review. JAMA, 2000. 283(9): p. 1183-1188.
  2. Mielniczuk, L.M., et al., Frequency of Peripartum Cardiomyopathy. The American Journal of Cardiology, 2006. 97(12): p. 1765-1768.
  3. Fett, J.D., et al., Peripartum cardiomyopathy in the hospital Albert Schweitzer district of Haiti. American journal of obstetrics and gynecology, 2002. 186(5): p. 1005-1010.
  4. Fett, J.D., et al., Five-year prospective study of the incidence and prognosis of peripartum cardiomyopathy at a single institution. Mayo Clin Proc, 2005. 80(12): p. 1602-6.
  5. Lampert, M.B., et al., Peripartum heart failure associated with prolonged tocolytic therapy. Am J Obstet Gynecol, 1993. 168(2): p. 493-5.
  6. Brockington, I.F., Postpartum hypertensive heart failure. Am J Cardiol, 1971. 27(6): p. 650-8.
  7. Cunningham, F.G., et al., Peripartum heart failure: idiopathic cardiomyopathy or compounding cardiovascular events? Obstet Gynecol, 1986. 67(2): p. 157-68.
  8. Walsh, J.J., et al., Idiopathic Myocardiopathy of the Puerperium Circulation, 1965. 32: p. 19-31.
  9. Mendelson, M.A. and J. Chandler, Postpartum cardiomyopathy associated with maternal cocaine abuse. Am J Cardiol, 1992. 70(11): p. 1092-4.
  10. Gentry, M.B., et al., African-American Women Have a Higher Risk for Developing Peripartum Cardiomyopathy. Journal of the American College of Cardiology, 2010. 55(7): p. 654-659.
  11. Bultmann, B.D., et al., High prevalence of viral genomes and inflammation in peripartum cardiomyopathy. Am J Obstet Gynecol, 2005. 193(2): p. 363-5.
  12. Warraich, R.S., et al., Impact of pregnancy-related heart failure on humoral immunity: clinical relevance of G3-subclass immunoglobulins in peripartum cardiomyopathy. Am Heart J, 2005. 150(2): p. 263-9.
  13. Kara, R.J., et al., Fetal cells traffic to injured maternal myocardium and undergo cardiac differentiation. Circ Res, 2012. 110(1): p. 82-93.
  14. Hilfiker-Kleiner, D., et al., A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell, 2007. 128(3): p. 589-600.
  15. Sliwa, K., et al., Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation, 2010. 121(13): p. 1465-73.
  16. Patten, I.S., et al., Cardiac angiogenic imbalance leads to peripartum cardiomyopathy. Nature, 2012. 485(7398): p. 333-8.
  17. Elkayam, U., et al., Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation, 2005. 111(16): p. 2050-5.
  18. Napporn, A.G., et al., [Intraventricular thrombosis complicating peri-partum idiopathic myocardiopathy]. Ann Cardiol Angeiol (Paris), 2000. 49(5): p. 309-14.
  19. Amos, A.M., W.A. Jaber, and S.D. Russell, Improved outcomes in peripartum cardiomyopathy with contemporary. Am Heart J, 2006. 152(3): p. 509-13.
  20. Fett, J.D., K.L. Fristoe, and S.N. Welsh, Risk of heart failure relapse in subsequent pregnancy among peripartum cardiomyopathy mothers. Int J Gynaecol Obstet, 2010. 109(1): p. 34-6.
  21. Rasmusson, K., et al., Long-Term Outcomes in Patients With Peripartum Cardiomyopathy and No Recovery of Ventricular Function. Journal of cardiac failure, 2010. 16(8): p. S97.
  22. Zimmerman, H., et al., Treatment of peripartum cardiomyopathy with mechanical assist devices and cardiac transplantation. Ann Thorac Surg, 2010. 89(4): p. 1211-7.
  23. O’Connell, J.B., et al., Peripartum cardiomyopathy: clinical, hemodynamic, histologic and prognostic characteristics. J Am Coll Cardiol, 1986. 8(1): p. 52-6.
  24. Elkayam, U., et al., Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. N Engl J Med, 2001. 344(21): p. 1567-71.

 

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Spotlight on Neuroscience

Wednesday, November 25th, 2015

By Helen K. Kelley

The field of neuroscience is ever changing and expanding, with physicians and researchers working separately and together, using cutting-edge technologies and techniques to advance the understanding of the brain and nervous system.

Minimally Invasive Technologies Improve Cerebrovascular Treatments

Continuous advances in technology are making it possible to treat cerebrovascular disease, strokes and aneurysms with greater precision and effectiveness, according to Rishi Gupta, M.D., director of the Neurocritical Care Unit and Telestroke Network at WellStar Health System. One such treatment is a catheter-based approach for patients suffering from strokes.

Gupta Rishi“In the past, a patient suffering from one of these conditions would receive thrombolytic therapy to break up or dissolve blood clots. Today, we have catheters that we can use to remove clots and treat brain blood vessel disorders,” he says.

Dr. Gupta says that new technologies have especially improved surgeon’s capabilities to remove blood clots.

“There has been a rapid evolution of technologies to allow physicians to safely and effectively remove blood clots from the brain. Less than five years ago, we were able to open arteries by removing clots about 50 percent of the time; now, we are able to open arteries about 95 percent of the time. That improvement is attributable to technology,” he says. “The previous Merci device that is similar to a corkscrew has been replaced with retrievable stent-like devices – the Trevo device and the Solitaire device – that we can deploy to collapse and remove blood clots.”

A new and exciting technology for the removal of brain hemorrhages is the Apollo aspiration catheter.

“In the past, we had to open the patient’s skull to remove a hemorrhage. Now, we can use the Apollo device to pass a catheter through a tiny hole drilled in the skull, reach the clot and initiate aspiration to remove the bleed,” he says. “This technology allows us to access brain hemorrhages that previously could not be operated upon, and with only minimal disruption to the normal brain tissue.”

According to Dr. Gupta, new and advanced treatments and techniques are quickly changing the way stroke patients receive care.

“Stroke patients have more options today,” he says. “Now, by using approaches that are less invasive and with new technologies, we have been able to extend the window of time for treating these people. That allows us to do a lot more for them.”

Targeted Therapies for Brain Tumors

Erin Dunbar“The scope of neuro-oncology includes primary and metastatic cancers that affect the brain and the spine. The neuro-oncologist’s ‘bread and butter’ is metastatic disease – brain and spine metastases are 10 times more common than tumors that originate in the brain and spine,” says Erin Dunbar, M.D., director for neuro-oncology and one of the founding physicians of the Piedmont Brain Tumor Center. “Fortunately, there are some extraordinarily promising tumor-directed therapies – chemotherapies, radiations, surgeries and devices like tumor-treating shields – that we are using today to improve both longevity and quality of life for patients with both primary and metastatic tumors of the brain and spine.”

For example, in light of former President Jimmy Carter’s recent diagnosis of melanoma that has metastasized to other parts of his body including his brain, Dr. Dunbar says that a targeted medicine approach, immunotherapy, is making huge strides in treatment.

“Immunotherapy is exciting and showing promise in treating melanoma and lung cancer, including their brain metastases,” she says. “Additionally, it is being used to treat primary brain tumors like glioblastoma.”

Dr. Dunbar says that there is currently an explosion of new medicines being applied to tumor-directed therapy, both in terms of delivery mechanisms and the benefits to and tolerability for the patient.

“There are some amazing new medicines being applied to tumor-directed therapy, including vaccines that can harness [the] immune system and get it to fight the tumor. Traditional chemotherapy is only one tiny fraction of how we fight tumors with medicines now,” she says. “These vaccines and other immune system fighters and new chemotherapies are often outpatient therapies that patients can live with.”

One modality is a non-invasive device that the patient wears on his or her head. “[It’s] a biologic energy field that is designed by a certified physician to deliver a low-dose treatment right to their brain tumor,” Dr. Dunbar says. “The device is portable and empowers patients by giving them control of their therapy.”

Traditional treatments for brain tumors continue to improve as well, according to Dr. Dunbar.

“The technical components of radiation and surgery are becoming so precise that patients are receiving more effective therapy with fewer side effects than ever before,” she says. “The improvements are completely changing the way people get their care.”

Dr. Dunbar adds that the paradigm in oncology has evolved to a point where patients are benefiting from clinical trials and emerging technologies and therapies, at diagnosis and throughout their lifetimes. Patient-centered, multidisciplinary care teams are also essential to improvements in quality of life and longevity. And there have been advances in palliative care.

“Now we have board-certified palliative oncologists as well as providers in both palliative care and oncology specialties who are dedicated to aggressively preventing and managing complex symptoms,” she says.

Telemedicine Offers Hospitals 24/7 Access to Stroke Care

When it comes to stroke care, time is of the essence. Yet more and more hospitals are themselves without neurologists on staff, leaving them with a critical need for assistance in diagnosing and treating stroke patients.

Matt GwynnMatthews Gwynn, M.D., and his partners at Atlanta Neurology, Drs. Keith Sanders, Jim Kiley and Lisa Johnston, saw that they could provide this much-needed service to hospitals in real-time via the Internet. Six years ago, they founded AcuteCare Telemedicine (ACT), which offers cost-effective solutions that deliver complete on-call coverage, improve patient outcomes, adhere to HIPAA/HITECH requirements and establish a sustainable financial model for patient care.

“With the advent of high-speed Internet service, we saw the feasibility of treating emergency neurology patients through telemedicine in real time,” says Dr. Gwynn. “We started out providing the service to one hospital and are now serving 25 hospitals in five states, and the demand is still high and growing.”

Dr. Gwynn explains that ACT’s physicians are available to consult with hospital personnel and see the patient who presents with stroke symptoms within just minutes of notification.

Telemedicine“We’re able to actually see the patient via a webcam with a high-definition camera on a wide flat screen. The camera can pan, tilt and zoom all around the room so that we are able to view the patient, turn and talk with his or her family members, view lab results and scans … exactly as if we were in the room,” he says. “Then we can determine if the patient is having a stroke or experiencing something else and make recommendations for how to treat them. Our note goes into the patient’s chart immediately.”

Through ACT, hospitals are able to access a network of experienced, board-certified clinicians who are able to communicate clearly with patients, doctors, nurses and pharmacists, at a fraction of the cost they would incur for having neurologists on staff. But more important, they are able to provide immediate diagnosis and treatment for patients who may be experiencing stroke.

 

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WellStar Cobb Hospital Names New President

Saturday, November 21st, 2015

AmAmy Carriery Carrier has been named president of WellStar Cobb Hospital in Austell. 

Carrier brings more than 20 years of healthcare experience to WellStar.  She will manage Cobb Hospital’s financial performance and clinical quality, while using her extensive healthcare experience to develop and implement strategic growth initiatives.

“With her extensive experience in healthcare administration and process improvement, Amy Carrier is the right person to lead WellStar Cobb Hospital.” said Kem Mullins, former president of WellStar Cobb Hospital and current interim chief operating officer for WellStar Health System.

Before joining WellStar, Carrier served as corporate vice president of Business Development and Strategy for Adventist HealthCare in Maryland. Previously, she served as vice president and chief operating officer for Washington Adventist Hospital, where she also held positions as acting chief executive and interim chief financial officer.  She has also worked at Conemaugh Health System in Pennsylvania, Inova Fairfax Hospital in Virginia and George Washington University Medical Faculty Associates in Washington, D.C. Carrier has a master’s degree in business administration from Indiana University of Pennsylvania, a bachelor’s degree from Pennsylvania State University and has served as adjunct faculty at Georgetown University and The University of Maryland.

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November 2015 Trauma Commission Meeting

Thursday, November 19th, 2015

November 19, 2015, Atlanta. For more information, visit Georgia Trauma Commission 

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Where Cardiology and Vascular Care Go Hand in Hand

Thursday, November 19th, 2015

By Helen K. Kelley

The statistics on cardiovascular disease are startling. It is the leading cause of death for both men and women and for most ethnicities in the United States — according to the Centers for Disease Control, approximately 610,000 Americans die of cardiovascular disease every year, accounting for one in every four deaths. In fact, cardiovascular diseases claim more lives than all forms of cancer combined.

Faced with the formidable challenge that cardiovascular disease presents, Northside Hospital’s team is comprised of board-certified cardiologists, vascular surgeons, cardiovascular trained nurses and technicians who are leaders in the field of the treatment and prevention of heart disease, stroke and vascular diseases. Their integrated approach includes the latest technologies and surgical techniques, along with a comprehensive network of preventive, diagnostic, medical and support services, for treating patients with cardiovascular disease.

Northside HospitalExpansion, research, technology offer new options in cardiology

Northside’s cardiologists are dedicated to providing leading treatments for patients with cardiac conditions such as arrhythmias, coronary artery disease and heart failure, as well as early detection, diagnosis and management of other conditions that could potentially affect the heart, like high blood pressure, high cholesterol, diabetes and obesity.  Using advanced technology, the staff of cardiologists teams up with radiologists and technicians to diagnose and treat various cardiac conditions. They also perform invasive procedures to correct heart abnormalities, including pacemaker implementation, defibrillators, cardiac catheterization and stent placement.

Recently, expanded lab capabilities and the addition of staff have increased the Heart & Vascular Institute’s ability to diagnose and treat patients with cardiac issues, according to Michael Balk, M.D., Medical Director, Northside Heart and Vascular Institute.

“We’ve expanded our interventional and invasive labs, and we’ve added additional physicians,” he said. “As a result, we’re able to do more procedures. Plus, we now have a dedicated electrophysiology lab, where our electrophysiologists use the latest techniques to treat arrhythmias.”

As part of its mission to identify and treat heart disease earlier, Northside is participating in the National Heart, Lung and Blood Institute’s new research program involving low dose methotrexate. The drug, which has been used successfully to reduce inflammation in people who have arthritis, is currently being studied to see if it is effective in reducing cardiovascular inflammation.

“Doctors who were using methotrexate to treat patients for arthritis noticed that these patients also had fewer coronary events. Once this was discovered, it became important to determine whether or not the drug also could be effective in people with cardiac issues,” Balk explained.

The participants in this clinical trial are people who have experienced a heart attack or major blockage and who have additional comorbidities like diabetes or metabolic syndrome.

“We are looking at methotrexate as a treatment that can reduce inflammation and therefore, reduce the chance of a future heart attack or stroke in these individuals,” Balk explained. “If found to be effective, this drug may change how we treat patients in the future.”

Across the board, the Institute’s physicians are continuously seeking out ways to improve diagnoses and treatments.

“For example, our electrophysiologists are trained in techniques like cryoablation, which uses extreme cold to treat cardiac arrhythmias by ablating tissue. This technique can lower the risk of procedure-related complications in some patients,” Balk said. “Whether it’s electrophysiology, cardiology, nuclear cardiology, CT, angiography or vascular and interventional procedures, we’re always working to reduce risks and improve outcomes for our patients. Therefore, about 90% of our catheterization procedures are now done radially, a less-invasive approach,” Balk added.

Emphasis on early detection

Balk stresses that early detection of cardiovascular disease is a major focus for the Northside Heart & Vascular Institute, and that an aging baby boomer population has offered new reasons for changing the way cardiac problems are diagnosed. “As the demographic changes across the country, we will see larger numbers of age-related illnesses like atrial fibrillation, which is still on the rise,” he said.

Patricia Tyson, Administrative Director of Northside Heart & Vascular Institute, adds that early detection is especially beneficial to patients who are pregnant or looking to become pregnant.

“Nationally, the number one reason for maternal death and complications during the pregnancy and postpartum is cardiac-related such as embolism, preeclampsia and cardiomyopathy,” she said. “Therefore, we are working to identify those patients early and have specialists on our staff that focus on these complications in women during pregnancy and can intervene to prevent major issues and/or death.”

On the vascular side of early detection and treatment, the Northside Heart & Vascular Institute has a process called Code Rupture that alerts the hospital’s Emergency Department to the impending arrival of a patient experiencing a ruptured aortic aneurysm.

“Ruptured aortic aneurysm has one of the highest mortality rates for any health issue in the country. Our Code Rupture system is active and alerts the full ED team in advance to prepare for the patient who is being transported,” Tyson explained. “Through this effort, we’ve vastly improved the mortality rate from ruptured aortic aneurysm at Northside; in fact, it’s lower than the national average.”

Access to clinical trials, research devices offers benefits in treatment of vascular diseases

The vascular surgeons of Northside’s Heart & Vascular Institute are all academically trained physicians who have an interest in clinical research. Their education and training have provided the perfect set-up for the Institute to participate in clinical trials involving new, investigational devices that are undergoing testing, according to Siddharth Patel, a surgeon in the Department of Vascular Surgery and Endovascular Therapy.

“There are some clinical trials accessible to us that can potentially have significant benefits for our vascular patients. For example, there are drug-coated balloons and stents that were formerly available only in the cardio arena and are now available to the  patient with peripheral arterial disease, or PAD,” he said. “Additionally, many of these trials were formerly available only in the university setting.  Now, the Northside Heart & Vascular Institute is able to access these trials and we are excited to bring these treatments to our community.”

CardiologyPatel cites two clinical trials currently underway for technologies that may soon benefit Northside patients — the Gore branched stent graft, used to treat iliac artery aneurysms while maintaining pelvic perfusion, and Bolton’s Treovance endograft, which has a smaller caliber that may be useful in delivering treatment to patients with smaller arteries, particularly females. He adds that Northside’s vascular team has an interest in participating in several upcoming trials, including a bedside intravascular ultrasound-guided vena cava filter for patients who are too unstable to transport to the fluoroscopy suite or patients with renal insufficiency who cannot receive contrast, and a drug-coated balloon catheter that can be used to treat lesions in the tibial arteries below the knee.

Dr. Patel also described an exciting new technology available at Northside, the Magellan endovascular robotic system. “This new robotic tool will allow us to deliver therapy with increased precision and efficiency for everything from carotid stenting to visceral and renal procedures to lower extremity interventions, thereby reducing the radiation dose for both the patient and the endovascular team. We are very excited to be the only health system in Georgia with the robot. In fact we have two, one at Northside Atlanta and one at Northside Forsyth, which is amazing considering there are only 14 total in the entire country. This speaks volumes about how committed Northside Hospital is to improving the care of the vascular patient.”

Collaboration reaches patients far beyond metro Atlanta

The Northside Heart & Vascular Institute’s network of cardiologists and vascular surgeons extends well outside the walls of Northside’s flagship hospital in Atlanta. Many physicians located throughout Georgia, utilize the vast network of specialists and leverage the Institute’s services for their patients.

Utpal H. Pandya, M.D., Chief of Cardiology with Kaiser Permanente’s Southeast Permanente Medical Group, says his association with the Northside Heart & Vascular Institute has provided a critical partnership.

“We [Southeast Permanente Medical Group] perform a wide range of diagnostic and interventional procedures, and many of our cases are at Northside,” he said. “They provide good service to our patients; moreover, they assist us in areas such as documenting heart failure readmissions and medication compliance. This collaboration is, in fact, critical to our success.”

Additionally, the collaboration offers access to the latest technologies and clinical trials to a wider patient base.

“The physician’s struggle in any highly expensive field of medicine, like cardiology, is the desire to treat patients with the newest tools available. But we always have to face the economic realities,” said Pandya. “However, the Northside Heart & Vascular Institute works very hard to bring those tools to us. They welcome our input and decision-making is collaborative. This partnership has worked very well.”

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Unraveling the Mystery

Thursday, November 19th, 2015

A brief history of medical genetics and Emory’s team 

By Michael J. Gambello, MD, PhD

Medical genetics is a relatively new subspecialty that is a mystery to many healthcare providers as well as the general public. We hope to unravel some of this mystery in this issue of Atlanta Medicine and enlighten you on some aspects of our practice at Emory.

At Emory, we do diagnose and manage rare diseases, which collectively are not that rare – but this is not exclusively so. Medical genetics involves the diagnosis and management of hereditary diseases, or the “science of human biologic variation as it relates to health and disease,” to quote Victor McKusick1, one of the fathers of medical genetics.

In spite of these definitions, our daily role is still not clear. However, by looking at the history of medical genetics and Emory’s role in this fascinating and technology-laden world, perhaps these definitions can be put in a better perspective.

GeneticsA Brief History of Medical Genetics

Many clinicians noted familial segregation of disease before medical genetics surfaced as a young specialty in the 1950s. Over the next several decades, major discoveries in the basic science of human genetics led to the development of medical genetics. Noteworthy areas of discovery occurred in cytogenetics (the study of chromosomes), inheritance of discrete traits (sometimes called Mendelism, after Gregor Mendel’s studies on wrinkled and round peas), biochemical, population and molecular genetics.

The 1950s were transformative years. In 1953, Watson and Crick, using important data from Franklin and Wilkins, discovered the double helical structure of DNA, noting “it has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.”2

In 1956 Tjio and Levan developed a novel method to analyze chromosomes under the microscope and determined that humans have 46 chromsomes 3. In 1959 Lejeune showed that an extra chromosome 21 was the cause of Down syndrome, soon to be followed by the chromosomal nature of Turner syndrome and Klinefelter syndrome1. During this time, the central dogma of molecular biology was also established: DNA is transcribed into RNA that is translated into protein.

The genetic code was “broken” in 1966 by the combined work of Holley, Khorana and Nirenberg and others. A three nucleotide codon specifies which amino acid will be incorporated into a protein. The first World Congress of Human Genetics was held in Copenhagen in 1956. The first chair of Medical Genetics, Maurice Lamy, was appointed in Paris. In 1957, specific medical genetics departments open in Baltimore (Victor McKusick at Johns Hopkins) and Seattle (Arno Motulsky at the University of Washington).

Victor McKusick, considered the father of medical genetics by many, published Mendelian Inheritance in Man (MIM), a catalogue of autosomal dominant, autosomal recessive and X-linked phenotypes. The exponential increase in genetic knowledge has transformed MIM to OMIM – Online Mendelian Inheritance in Man – A catalogue of Human Genes and Disorders.

In 1977, Sanger developed a novel method of sequencing DNA, and the molecular era was full speed ahead. Using families and linkage analysis, gene identification and mapping for many Mendelian disorders were accomplished. In 1991, the American Board of Medical Genetics (ABMG), became the 24th organization to join the American Board of Medical Specialties. This board gives oversight to the training and practice of medical genetics.

By 1984, plans were underway to determine all the A’s, T’s, G’s and C’s that comprise the human genome, called The Human Genome Project. The project began in 1990 and was finished in 2003. It is amazing that only about 1 percent of the genome actually codes for genes (termed the exome) and that we only have about 20,000 genes. (Given the size of our genome, it was thought that we had at least 100,000.) The remaining 99 percent of our genome appears to regulate gene expression, but there is still much research to be done.

Over the past 10 years, DNA sequencing technologies (called massively parallel sequencing) have improved tremendously, permitting whole exome sequencing (only 1 percent of the genome, i.e. coding genes only) for diagnostic testing in medical genetics. The next technology challenging medical genetics is whole genome sequencing. While The Human Genome Project cost $2.7 billion and took 13 years, a whole human genome now costs about $2,000 and can be done within a week.

Indeed we are in the genomics age, where we are now sequencing, assembling and analyzing the function and structure of genomes. Recently the ABMG changed its name to the American Board of Medical Genetics and Genomics to reflect the importance of genomics in our practice.

Medical genetics has indeed evolved quickly in just over 60 years. Today, there are many Medical Genetics Departments and Divisions throughout the U.S. that assist healthcare givers and patients navigate the rapidly advancing field of medical genetics.

Emory GeneticsThe Division of Medical Genetics at Emory

The Division of Medical Genetics at Emory University School of Medicine (genetics.emory.edu) was founded in 1970 by Louis “Skip” Elsas II, M.D. Medical genetics was then part of the Department of Pediatrics to reflect a heavy emphasis on pediatric medicine. In 2001, Stephen Warren, Ph.D., founded the Department of Human Genetics at Emory. By 2002, the Division became formally affiliated with the Department of Human Genetics.

This structure reflects an important historical and synergistic relationship between the clinical and basic sciences. While we certainly still care for many children, our practice has a much larger scope. The Division is composed of a variety of genetic providers, including physicians (the medical geneticists), genetic counselors, metabolic nutritionists, nurses, psychologists, a developmental pediatrician and other support staff.

Medical geneticists are physicians who have completed a two-year ACGME (Accreditation Council for Graduate Medical Education) accredited program in medical genetics. Typically, physicians who train in medical genetics have already completed a residency in a primary care specialty such as pediatrics, internal medicine, family medicine or obstetrics-gynecology.

Medical geneticists are encouraged to become Board Certified by the American Board of Medical Genetics and Genomics. The Board exists to protect the public by maintaining high standards for the practice of medical genetics. Emory has an ACGME-accredited training program in medical genetics (genetics.emory.edu/education). We provide inpatient consultation for Children’s Healthcare of Atlanta at Egleston/Scottish Rite and Emory University Hospital.

We have about 4,000 outpatient visits a year, and we anticipate 5,000 next year. Our patient population is diverse, and the subsequent sections of this issue will help you understand the scope of our practice and when your patient might need a consultation with the medical genetics team. Keep in mind that our mission is not only excellent patient care, but also research and teaching. Many of us are involved in discovering the genetic causes of new disease, conducting clinic trials, and teaching in the classroom and clinic.

Genetic counselors are health professionals who form an integral part of the medical genetics team. They complete a two-year ACGC (Accreditation Council for Genetic Counseling) accredited graduate program to gain experience in medical genetics, research and counseling. Students come from a variety of disciplines such as biology, nursing, social work, psychology and public health. The National Society of Genetic Counselors states that “genetic counseling is the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.”

In practice, their role varies widely. Some functions include taking medical and family histories, coordinating and interpreting genetic testing to patients and healthcare providers, coordinating clinical trials and teaching. Emory has an ACGC-accredited training program (genetics.emory.edu/gc_training) and is always looking for enthusiastic students.

Metabolic dietitian is another highly specialized profession. These healthcare providers help care for patients with inborn errors of metabolism, or biochemical genetic disorders. Some of these disorders result from a genetic defect in an enzyme that is important for detoxifying too much of a metabolite, or making energy. Most readers are familiar with phenylketonuria (PKU) – the inability to breakdown excess phenylalanine. Adherence to a strict diet from infancy prevents severe intellectual disability. In fact, the success of dietary treatment for PKU was a major impetus for the introduction of newborn screening programs that will be discussed in a subsequent section. We now screen for more than 30 disorders and identify many children and families who benefit from the expertise of a metabolic dietitian.

In this issue of Atlanta Medicine, you’ll find articles by many of my colleagues about various aspects of medical genetics, from infancy to adulthood. We have omitted prenatal genetics, which is managed almost exclusively by Maternal Fetal Medicine experts at Emory and other programs, though we often communicate with them when addressing reproductive options for families.

We hope that these brief articles will better define what we do and how we might be able to help you and your patients. Rossana Sanchez, M.D., is a trainee in our medical genetics residency. She gives you a concise description of when your patients might benefit from a medical genetics consultation. Suma Shankar, M.D., Ph.D., reviews aspects of medical genetics and pediatrics. Hong Li, M.D., Ph.D., gives an excellent description of newborn screening programs and biochemical genetics. Jaime Vengoechea discusses some genetic disorders of adult medicine. Bill Wilcox, M.D., Ph.D., demonstrates that we are not merely diagnosticians, but do indeed treat many genetic diseases.

 

References

  1. McKusick VA and Harper PS. 2013. History of Medical Genetics. In:Rimoin DL, Pyeritz RE, Korf BR ed. Emery and Rimoin’s Principles and Practice of Medical Genetics. Elsevier pp.1-39.
  2. Watson JD, FHC Crick. Molecular structure of nucleic acids.1953 Nature 171:737-738.
  3. Tjio JH, Levan LA. 1956. The chromosome number of man. Hereditas 42:1-6.
  4. UK Genetics Archive Project (<www.genmedhist.org/Records>).
  5. Human Genetics Historical Library (see <http://www.genmedhist.org/HumanHistLib/>). A collection of over 3000 books.
  6. Harper, P. S. A Short History of Medical Genetics; Oxford Univer- sity Press, 2008.
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NFMGMA Meeting

Wednesday, November 18th, 2015

November 18, 2015, The Metropolitan Club, Alpharetta, Ga. For more information, visit Georgia Medical Group Management Association 

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