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Archive for September, 2016

Interventional Radiology

Friday, September 30th, 2016

By Helen K. Kelley

Interventional Radiology

By Mbarrufet – Own work, CC BY-SA 4.0

Interventional radiologists continue to expand the number of diseases and conditions that can be treated with minimally invasive techniques. Atlanta Medicine recently spoke with two Atlanta-area physicians who are performing some innovative procedures for patients with certain types of cancer, spine fractures, neuropathies and more.

Image guidance improves efficacy of cancer treatments

Praveen Reddy, M.D., a vascular and interventional radiologist with Northside Radiology Associates, says that advances in interventional radiology (IR) are making a big difference in the oncology field.

“Today, we have a wide spectrum of interventional treatments that can help cancer patients, from basic procedures like installing chest ports that are used to deliver chemotherapy to chemoembolization, in which anti-cancer drugs are injected directly into the blood vessel feeding a cancerous tumor. For example, to treat liver cancer, we can insert a catheter into the hepatic artery for direct delivery of chemotherapy,” he says. “In addition to chemotherapy, we have techniques for the direct delivery of radiation and local treatments with ablative therapy with radiofrequency ablation, cryoablation and microwave ablation.”

Dr. Praveen Reddy

Dr. Praveen Reddy

Reddy adds that people with osteoporosis often experience fractures of the spine that can be treated successfully through an interventional radiological technique.

“For this condition, we insert needles into the spine to inject a compound that stabilizes the fractures. Most patients experience relief from their pain within hours,” he says. “This procedure is especially beneficial for older adults who are at higher risk for developing pneumonia and other illnesses if they cannot be active.”

Additionally, IR is a mainstay in women’s interventions, including uterine artery and emergent embolization, according to Reddy.

“One of the most common procedures we perform is uterine artery embolization for symptomatic fibroid tumors. It’s a nonsurgical treatment that stops the blood flow to the fibroids and gives relief from symptoms such as bleeding and pain,” he says. “We can also perform emergent embolization with Caesarian sections and baby deliveries that have gone awry to stop significant bleeding.”

Reddy states that data being gathered from clinical trials has proven efficacy of these and other IR procedures.

“We’re currently looking at the data for the interventional delivery of chemotherapy and checking survival rates for cancer patients who receive it,” he says. “The results are promising.”

Cyroblation therapy improves lives of people with chronic pain

Dr. David Prologo

Dr. David Prologo

David Prologo, M.D., associated with Emory University School of Medicine’s Division of Interventional Radiology, has focused his research on helping patients who are experiencing chronic pain. He has found notable success in treating patients who have painful cancers, phantom limb pain and more by using image guidance to deliver cryoablation therapy.

“In our ‘day job’ as interventional radiologists, we traditionally perform treatments with percutaneous probes to deliver therapies to targeted areas,” he says. “But in cryoablation therapy, we use probes and image guidance to target nerves and deliver a freezing ablation to deaden the pain.”

Prologo says that the true innovation of the treatment is due to the marriage of existing technologies.

“Interventional radiologists were already using the probes for other procedures, and image guidance was being used for other conditions like biopsies and trauma injuries,” he says. “By using these same tools to address painful conditions, we have been able to offer unique options for patients whose pain has been essentially deemed untreatable in the past.”

Usually guided by a CT scanner, cryoablation therapy is delivered via a 17-gauge needle, through which Argon gas flows to create an ablation zone of cold. Wherever the needle is placed, that ablation zone is formed.

Prologo says the number of applications that can be successfully treated with cryoablation therapy continues to expand.

“We’ve found it helps people who suffer from neuralgia, phantom limb pain, neuropathies, back pain and pain related to spinal cord injury,” he says. “But the granddaddy of them all is cancer pain. People with metastatic cancer can get relief with this treatment.”

Prologo adds that he would like to get the word out to amputees and veterans that cryoablation therapy can help them with the phantom limb pain they experience.

“We know that in the U.S. today, there are at least 2,000 amputees from war in the past 10 years. In our practice, we’ve seen a few veterans, but not nearly the number in our area that suffer from phantom limb pain,” he says. “We haven’t been able to reach these veterans the way we’d like. So we’re applying to the Department of Defense for grant funding in order to perform this procedure for our veterans in need.”

To date, Prologo and his colleagues have treated more than 200 patients using percutaneous palliative cryoablation, but he says that it is not known yet whether the effects are permanent.

“The therapy is so new that we don’t know the long-range effects yet,” he says. “But it appears to be long-lasting.”

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Is a Workers’ Compensation Practice Right for You?

Friday, September 30th, 2016

What you need to know to develop a successful and rewarding practice

By Snehal Dalal, M.D.

 

Successfully diagnosing, treating and returning workers’ compensation (WC) patients can be a rewarding part of a physician’s practice. However, not all of us are meant to take care of these type of cases.

There must be a commitment on the part of the provider to give extra time, fill out paperwork and handle specific issues. One must be comfortable in treating not only clear-cut cases but also those patients with vague symptoms without a specific injury.

We are usually accustomed to dealing with only patients and their families. With workers’ comp cases, correspondence from adjusters, case managers and even attorneys must often be handled. Sometimes communication is required to resolve conflicts in opinions.

As professionals, we must not only treat but also educate employers, insurers and case managers as well as help prevent injury in the workplace.

For patients with a workers’ compensation-related medical issue, having to take time off due to injury is quite distressing. The fear of losing one’s job due to an inability to keep up with what the position demands can cause anxiety. It may also put the patient at risk of further harm in their attempts to continue working while injured.

As an orthopaedist and sports medicine physician, I approach the injured worker as an athlete. I want to return the patient back into the game as soon as possible. Getting a patient back to gainful employment can be equally rewarding as getting an athlete back to their sport.

HOW IS THE INJURED WORKER DIFFERENT?

As the Authorized Treating Physician (ATP) in Georgia, we must diagnose and present a treatment plan for the injured worker that determines:

Causation: Is the injury due to direct trauma or overuse from job duties?

Work status: Is it safe for the patient to return to full or restricted duty and how soon?

Treatment Course: What is the anticipated time frame to Maximal Medical Improvement (MMI)?

Legal issues: What is the anticipated permanent impairment and functional limitations once the patient is deemed to be at MMI?

MAXIMIZING GOOD OUTCOMES

As we establish the doctor-patient relationship, it is paramount to be impartial and ensure that you have the best interest of your patient. After all, you are the patient’s best advocate. It is important to emphasize active patient participation and set expectations from the beginning. One a treatment plan is devised, it is important to educate the patient, case manager, adjuster, attorney and your Workers Compensation Coordinator.

Closer follow-up is a good idea to ensure patient compliance and insurance approval. This also allows changes to job restrictions as the patient’s symptoms improve or regress. If the patient is not improving, reconsider treatment options and/or diagnosis. Keep in mind that the importance should be placed on injury healing for functional restoration over subjective pain relief. This is critical when determining surgical intervention.

Prior to deciding on a procedure, ask why and how you have come to the conclusion to intervene. It is very important that the mechanism of injury, history, symptoms and exam positively correlate.

RETURN TO WORK

When determining when an injured worker may return to their job, the provider should emphasize return to work, even with restrictions, within 2-3 weeks from injury or surgery. This will keep the patient in his/her routine. Patients can return to work even if in chronic pain as long as they are functional and the job duties do not increase risk of further injury. It has been shown that patients out of work more than 6 months are unlikely to return.

Understand the demands of the workplace or job of the patient. Show interest, evaluate the job description and familiarize yourself with in-house occupational health staff. The patient will appreciate that you understand their perspective and understand that you aren’t with the employer “just to get them back to work.”

Illness behavior resulting in secondary gain can lead to prolonged perceived disability by patient. To deter avoidance behavior, encourage normal behavior and function. Involve case management or consider secondary gain if patient does not progress as expected in a 6-12 week timeframe.

Be aware of the many factors that may cause the patient to fail to return to pre-injury work status:

  • Some legitimate patients cannot return to work safely due to the nature of injury or high demands of job
  • Employers are not willing to accommodate restrictions
  • Malingering/secondary gain
  • Psychological issues
  • Worker dissatisfaction with employer
  • Symptom magnification

CAUSATION

Recognize that many injuries, particularly those that arise from “overuse” happen insidiously and only are recognized or manifested at work. These are not necessarily related to work.

The concept of contralateral injury due to ‘overcompensation’ is a red flag and should be approached with caution.

FAIRNESS

Give the patient benefit of the doubt. There is a tendency to find fault with the treating physician in the private pay sector and a tendency to find fault with the patient in the workers’ compensation arena. There are times that the physician may have had the wrong diagnosis, resulting in the patient having protracted symptoms. Leave judgement at the door, and keep an open mind when evaluating second opinions or IME.

Evaluate each patient thoroughly, objectively and honestly. Be impartial.

KEEP GOOD RECORDS, and COMMUNICATE!

Documentation is more important here than anywhere else. Workers’ compensation cases are highly litigated, and you may be asked to give testimony based on your medical records.

In general, keep clean, concise documentation in your practice. Electronic medical records (EMR) can be cumbersome, but these are very helpful in keeping track of phone calls, visit status reports(VSR), and work status forms and other correspondence.

Be proactive in communication with the case managers and adjusters. Avoid situations where someone must read your mind because they have to rely solely on your clinic notes. Identify problem cases, and bring them to their attention. With early communication, case managers may help expedite the treatment process. Provide timely notes to the adjuster with work restrictions.

Getting the patient to MMI is helpful, as their functional status may improve after settling a case. Get out Permanent Partial Disability (PPD) ratings as soon as possible to facilitate this.

PEARLS/PITFALLS

Market yourself to get yourself on panels. Panels can change quickly and often, so stay in touch with the insurance carriers and employers.

Use other peers on the panel for second opinions to help reinforce the treatment plan.

Never belittle or criticize other medical providers. This will only adversely affect your credibility.

Although Georgia law allows the authorized treating physician (ATP) to dictate treatment, it is good practice to seek pre-approval through the WC insurance provider. Also try to use the insurance-preferred providers. Of course always have the best interest of the patient, and deviate if necessary. Early and clear communication is important so you can present your case and the carrier can see why you have made specific recommendations.

Pain management may be helpful, but put a limit on the course of treatment to discourage chronic treatment.

As your WC practice grows, your time will become increasingly limited. Therefore, I recommend employing a Workers’ Compensation Coordinator to help streamline the treatment and communication process with all involved parties.

Many physicians shy away from a workers’ compensation-focused practice because the process is misunderstood or appears too time consuming. Realize that the vast majority of injured workers are eager to return to work and carry good outcomes.

With a little more understanding of the process and the willingness to put in the appropriate time, hopefully more highly qualified physicians will take on the task of helping our injured workers.

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Emory will study use of FDA-approved drug in HIV positive patients receiving kidney transplants

Friday, September 30th, 2016

The Emory Transplant Center will soon begin enrolling HIV (human immunodeficiency virus) positive patients in need of a kidney transplant into a new clinical trial to evaluate the safety and tolerability of a drug that blocks the CCR5 receptor. The CCR5 receptor is an entrance point for HIV into cells of the immune system. The drug being studied, generic name maraviroc, is an antiretroviral drug currently FDA-approved for the treatment of HIV infection.

Ten centers across the U.S. are involved in this prospective, double-blind, Phase II study. A total of 130 participants with well-controlled HIV infection (must be on an antiretroviral regimen for at least three months) will be randomized into one of two study arms: In one arm, 65 patients will receive maraviroc and in a second arm, 65 patients will receive a placebo. Neither doctors nor patients will know if the kidney recipients are receiving the study drug or the placebo (known as the standard of care).

Up to 11 participants will be enrolled at Emory. At all sites, participants will only receive kidneys from donors who are not infected with HIV.

“When it comes to transplanting organs in HIV positive patients, it is known that these patients have more rejection and more severe rejection than non-HIV transplant recipients,” says Thomas Pearson, MD, DPhil, professor of surgery, and executive director of the Emory Transplant Center. “This is likely because their immune systems are dysregulated and some components are overactive. This may contribute to the high rate of transplant rejection.” Pearson is the principal investigator of the Emory clinical trial.

CCR5 blockade is currently used in combination with other drugs to control HIV infection, but it has not been studied at the time of transplantation in HIV positive individuals.

“Besides testing CCR5 for safety and tolerability, we will also study its effects on quieting the immune response to transplant in HIV positive patients,” explains Pearson. “This clinical trial will help us better understand the drug’s effects on renal function at 52-weeks post-transplant and if the drug can have a dual effect in controlling the HIV infection and improving kidney transplant outcomes.”

All participants in the study will receive immunosuppressive medications following their transplant, as any transplant patient would. They will be followed for up to three years after transplant.

This $1.6 million research study for all 10 sites combined is supported by the National Institute of Allergy and Infectious Diseases (ClinicalTrials.gov Identifier: NCT02741323).

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Dr. Charles Brown named CEO of Piedmont’s Physician Enterprise

Friday, September 30th, 2016

Dr. Charles Brown - PiedmontCharles L. Brown, III, MD, has been named CEO of Piedmont’s Physician Enterprise, which consists of Piedmont Heart, Piedmont Medical Care Corporation, the Piedmont Clinic and other clinical programs.

“Dr. Brown is a proven leader,” Kevin Brown, CEO of Piedmont Healthcare, said. “He has led Piedmont Heart since its inception and has helped Piedmont earn a national reputation for cardiovascular research and care. I’m confident in his ability to take Piedmont’s Physician Enterprise to the next level.”

Board certified in cardiovascular disease, internal medicine and interventional cardiology, Dr. Brown will be responsible for all aspects of clinical operations and care delivered by Piedmont’s Physician Enterprise.

“There’s a distinct patient-centered environment at Piedmont which is quite unique,” Dr. Brown said. “Here, it is a very collaborative initiative. We all work together to serve the patient. As CEO of Piedmont’s Physician Enterprise, one of my initial goals will be to foster even greater clinical collaboration to improve quality programs.”

An interventional cardiologist with Piedmont Heart, Dr. Brown plans to continue his clinical practice while serving as CEO of Piedmont’s Physician Enterprise.

Dr. Brown earned his medical degree from Louisiana State University School of Medicine before completing his internship, residency and fellowships in cardiovascular disease and interventional cardiology at Emory University affiliated hospitals.

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Researchers link Chinese Elm trees with increased fall pollen counts in Atlanta

Friday, September 30th, 2016

According to a study focused on changing pollen trends in Atlanta, an increasing pollen count during the fall pollen bloom may correspond with a growing presence of Ulmus parvifolia or Chinese Elm trees. The study, conducted collaboratively by Emory University and Atlanta Allergy & Asthma Clinics, is published online this month in the Annals of Allergy, Asthma & Immunology.

The Southeast has an intense spring pollen season from January to April resulting from tree pollen counts that are often within the very high zone. In past years, the fall pollen season has been less intense, characterized by weed pollen, predominantly ragweed.

The study found that from 2009 through 2015 there were high levels of Chinese Elm tree pollen during the months of August and September. The pollen counts were consistently within the moderate range for trees, as determined by the local National Allergy Bureau criteria, greater than 15 grains per cubic meter. Peak counts of Chinese Elm ranged from 39 to 475 grains per cubic meter, notably with a greater number of days within the moderate pollen range and longer duration of the fall pollen season.

“Our study reveals that Chinese Elm is now an important autumn aeroallergen and should be considered in patients having predominant late summer-fall symptoms,” says lead author Marissa R. Shams, MD, assistant professor of allergy/immunology, Emory University School of Medicine.

In the past, Chinese Elm has not been a local aeroallergen in Atlanta, as it is native to Asian continent. According to researchers, because of a variety of climatic, environmental and societal factors throughout the years, the prevalence of Chinese Elm pollen has increased.

“These findings show that the changes in increasing pollen count corresponded with changes in landscape practices and the increased use of Chinese Elm Trees in home gardening.”

Chinese Elm trees are favored by landscapers and gardeners for their shade, low maintenance and beauty. They are also resistant to Dutch Elm disease and thrive in the urban and suburban Southeastern climate, as noted in the study.

According to Shams, if patients have predominant late summer-fall allergy symptoms or fail to respond to ragweed immunotherapy it may prompt further testing and modification of their current treatment regimens.

Additionally, she says this information illustrates that allergists need to remain aware of their local environment and changing trends in local pollen patterns.

The study was co-authored by Stan Fineman, MD, Atlanta Allergy & Asthma Clinics. Other supporters included Bodie Pennisi, PhD, University of Georgia; Laura Beverage, Greer Labs; and staff at the National Allergy Bureau pollen-counting station at Atlanta Allergy & Asthma Clinic, Kennestone.

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Drs. Adam Sunderland and Mike Starecki Join Resurgens

Friday, September 30th, 2016

Resurgens Orthopaedics has added two new physicians who will work out of its Austell, Douglasville and West Cobb locations: Dr. Adam Sunderland and Dr. Mike J. Starecki. The addition of these two new physicians to the practice will provide more physician coverage for the Southwest region’s future expansion in the Smyrna/Vinings area in early 2017.

Dr. Sunderland’s areas of expertise include total hip and knee replacement (including anterior approach total hip replacement), minimally invasive joint replacement, partial knee replacement, revision hip and knee replacement and lower extremity trauma. He completed his medical degree at Chicago Medical School and performed his residency at the Henry Ford Health System in Detroit. He completed a fellowship in adult reconstruction at Emory University Hospital. Dr. Sunderland is board-eligible before the American Board of Orthopaedic Surgeons and is a member of the American Association of Hip and Knee Surgeons and the Georgia Orthopaedic Society.

Dr. Starecki’s areas of expertise include hand and upper extremity surgery, microsurgery, carpal tunnel syndrome and reconstruction surgery of the hand, elbow and shoulder. He earned his undergraduate degree at Emory University and completed his medical degree at the Medical College of Georgia in Augusta. He performed his residency in orthopaedic surgery at Northwell Health in New Hyde Park, N.Y., and completed a fellowship at the New York University Hospital for Joint Diseases. He is board-eligible before the American Board of Orthopaedic Surgeons. He is a member of the American Society for the Surgery of the Hand.

Dr. Douglas W. Lundy, Resurgens Orthopaedics’ Co-President, said the practice is pleased to add physicians who are trained in the latest surgical techniques, including microsurgery and anterior approach total hip replacement.

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Aortic Stenosis: Emory Reaches Treatment Milestone, FDA Approval Announced

Friday, September 2nd, 2016

The U.S. Food and Drug Administration (FDA) has approved the expanded use of the SAPIEN 3 transcatheter heart valve, a non-surgical treatment option for patients with failing aortic valves.

The SAPIEN family of valves, developed by Edwards Lifesciences, has been under study and in use at the Emory Heart & Vascular Center since 2007. The valve offers a lifesaving alternative for patients with aortic stenosis, a serious heart condition that affects tens of thousands of Americans each year when the aortic valve tightens or narrows, preventing blood from flowing through normally.

Emory structural heart and valve centerThe newly announced FDA approval will allow the SAPIEN 3 valve to be used in the treatment of patients who are at intermediate-risk of open-heart surgery with severe, symptomatic aortic stenosis.

The SAPIEN 3 was approved by the FDA in June 2015 for the treatment of high-risk patients with severe, symptomatic aortic stenosis who are not candidates for open-heart valve replacement surgery.

During the procedure, the physician threads a replacement tissue valve to the heart through a catheter placed in the groin or ribs.

“The SAPIEN 3 valve has set a new standard for performance and patient outcomes with aortic valve replacement,” says Vinod H. Thourani, MD, professor of surgery and medicine, Emory University School of Medicine and chief of cardiothoracic surgery at Emory University Hospital Midtown and co-director of the Emory Structural Heart and Valve Center with Vasilis Babaliaros, MD.

“Emory’s involvement in the clinical trial was instrumental in helping secure FDA approval of the first-generation SAPIEN valve in 2011 and we have remained deeply involved in the evolution of this critical treatment option for patients with aortic stenosis.”

Thourani, Babaliaros and their Emory colleagues are celebrating a milestone this month, performing 1,500 TAVR procedures to date. Combined, they have the largest experience in the Southeastern U.S. and Emory was one of the highest volume centers participating in the valve’s clinical trial.

Emory Healthcare’s comprehensive, cross-functional Structural Heart & Valve Center is a one-stop institution for all types of cardiac valve and defect treatments, from medical management to traditional surgical care. The Center offers full-service locations at Emory University Hospital, Emory University Hospital Midtown and Emory Saint Joseph’s Hospital. For more information, please visit www.emoryhealthcare.org/structuralheart.

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American Academy of Pediatrics – Georgia Chapter: 2016 Fall CME Meeting

Thursday, September 22nd, 2016

September 22-24, 2016 at the Westin Atlanta North at Perimeter. For more information, visit American Academy of Pediatrics – Georgia Chapter.

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Georgia College of Emergency Physicians: Rural Emergency Practice Conference

Saturday, September 24th, 2016

September 24-25, 2016, Georgia Center’s UGA Hotel and Conference Center, Athens. For more information, visit Georgia College of Emergency Physicians.

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Dr. Scott Miller Named Prostate Cancer Subcommittee Co-Chair for Georgia Cancer Control Consortium

Thursday, September 1st, 2016

Scott D. Miller, M.D., a robotic prostate surgeon with Georgia Urology, was named co-chair of the Prostate Cancer Subcommittee for the Georgia Cancer Control Consortium (GC3), an initiative of the Georgia Department of Public Health.

The GC3, more commonly known as the Georgia Cancer Plan, is tasked with reducing the impact and burden in the state of cancer, which is the second-leading cause of death in Georgia. An estimated 16,840 Georgians will die of the disease in 2016, according to the American Cancer Society, and an estimated 48,670 new cases will be diagnosed.

Prostate cancer has the highest incidence rate in the state of any cancer for the years 2008 to 2012 at 150.1 cases per 100,000 and it has the second-highest death rate for the same period at 24.6 per 100,000. Prostate cancer also is expected to rank third in new cases among all cancers in Georgia with 5,570 and it is expected to be in the top six in deaths at 730.

Dr. Miller, who was appointed as co-chair along with Dr. Nannette Turner of Mercer University by the GC3’s Steering Team, is an advocate of Prostate-Specific Antigen (PSA) testing.

“Starting at age 40, every man should learn how to reduce his risk of dying of prostate cancer,” said Dr. Miller, the founder of ProstAware, a nonprofit that seeks to use the worlds of music, sports and technology to engage men and their loved ones to create awareness about the dangers of prostate cancer. “Waiting for symptoms to develop almost always leads to diagnosing the disease at an incurable stage. Furthermore, early PSA testing provides a baseline to help evaluate levels later in life, as the rate of rise can help predict prognosis and need for additional testing.”

Nationally, non-hispanic black men suffer from prostate cancer at far greater rates than non-hispanic whites (an incidence rate of 208.7 per 100,000 in blacks compared to 123 in whites). Non-hispanic blacks also suffer from far greater prostate cancer death rates: 47.2 per 100,000 compared to 19.9 for whites. Georgia mirrors these trends.

“The prostate cancer plight in Georgia is perpetuated by our state’s disparity in healthcare access and information,” Dr. Miller said. “Unfortunately, the population with lower access often overlaps with those groups at higher risk of developing prostate cancer.”

Through his work with the GC3, Dr. Miller hopes to reduce prostate cancer deaths for all Georgians.

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