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Archive for March, 2017

Thyroid Disease

Tuesday, March 28th, 2017

Thyroid disease is the leading endocrine disorder in the United States. While there are several different health issues that can result from either an overactive or underactive thyroid, thyroid cancer is the most prominent. The rate of thyroid cancer has tripled in the past three decades, likely due to better detection methods. Here, Atlanta Medicine shares the thoughts of two Atlanta area endocrinologists about recent strides in the detection and treatment of thyroid cancer, along with findings from a recent study on how thyroid disease affects pregnancy.

New Methods Reduce Need for Treatment

Nodules are abnormal growths on the thyroid that can be a warning sign of cancer. They can cause visible or palpable symptoms like a lump in the neck, hoarseness or trouble swallowing. or the person may experience no symptoms at all. Kate Wheeler, M.D.,

Kate wheeler md

Kate Wheeler, M buy cialis super active.D.

an endocrinologist with Laureate Medical Group, says that the latest methods for detection and evaluation of thyroid nodules have resulted in fewer people being treated for thyroid cancer.

“Whereas we used to put people through biopsies, sometimes unnecessarily, we now have ultrasound to help us get a better look at thyroid nodules,” she said. “The ultrasound helps us define the type of nodules that tend to be malignant and the characteristics of those that usually tend to be benign”

Dr. Wheeler says that improvements in the technology in recent years have given physicians the ability to judge the malignancy potential of thyroid nodules.

“The resolution of the ultrasound has gotten much better and allows us to see much finer detail,” she said. “Now, we’re able to look at margins, texture and blood flow, which are the characteristics by which we judge the malignant potential of a nodule. We’ve learned that, for some nodules, the chance of them ever becoming malignant is so unlikely that it would be totally unnecessary to put the patient through a biopsy.”

Dr. Wheeler adds that monitoring patients who have had thyroid cancer has also improved due to another method of evaluation — thyroglobulin level testing.

“The tests performed on someone who’s had thyroid cancer depend on the type of cancer he or she had. If the person received radioactive iodine therapy after a thyroidectomy, their doctor will test thyroglobulin level every year,” she explained. “Thyroglobulin assay has become so precise, you can get a lot of information just from that one test. If the thyroglobulin level is zero, it probably means the patient does not have cancer.”

Genetic Testing Can Help Patients Avoid Unnecessary Surgery

john h reed

John H. Reed, III, M.D.

According to John H. (Chip) Reed, III, M.D., a specialist in Internal Medicine, Endocrinology and Diabetes with Southeastern Endocrine & Diabetes, P.C., one of the biggest problems in the past for determining whether thyroid nodules are malignant or benign were biopsies that yielded indeterminate results. He says that advances in testing methods have made great improvements for both physicians and patients.

“When biopsy results of nodules were indeterminate, we were presented with a dilemma about how to treat the patient,” he said. “Ultrasound can tell us a lot about nodules, but we now have the ability to do genetic testing that can predict cancer.”

These genetics tests use thyroid cells obtained at the time of biopsy to screen for molecular markers for malignancy such as BRAF and RAS mutational states, mRNA classifier and high-density genomic data.  These tests are commercially available through a variety of laboratory companies.

“Previously, we often would end up surgically removing part or all of the person’s thyroid when biopsy results were indeterminate,” Dr. Reed said. “Gene expression testing gives us more definitive results that help prevent unnecessary surgeries when nodules are actually benign.”

When asked why the incidence of thyroid cancer has risen so dramatically in recent years, Dr. Reed says he believes it’s due to improved methods of detection.

“The big question about thyroid cancer is whether it’s becoming more common or if we’re simply finding it more than we used to,” he said. “In the past, patients and doctors had to actually feel something in the neck that would lead to testing. But now, routine carotid ultrasounds and neck CTs are detecting the nodules. I think the answer is that we’re just finding it more.”

Thyroid Disease in the News: New Guidelines for Management during Pregnancy

New evidence-based recommendations from the American Thyroid Association (ATA) provide guidance to clinicians in diagnosing and managing thyroid disease during pregnancy and the postpartum period. Pregnancy has a profound effect on thyroid gland function, and thyroid disease is common in pregnancy. The 97 recommendations presented in the new Guidelines help define current best practices for thyroid function testing, iodine nutrition, pregnancy complications, and treatment of thyroid disease during pregnancy and lactation.

The “2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease during Pregnancy and the Postpartum” were coauthored by an international task force of expert clinicians and researchers in the field of thyroidology. Led by Co-chairs Erik Alexander MD, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA and Elizabeth Pearce, MD, MSc, Boston University School of Medicine, the task force provides a solid foundation of knowledge on the assessment and treatment of thyroid disease in women during pregnancy, preconception, and the postpartum period. The Guidelines include recommendations related to the diagnosis and management of hypothyroidism, thyrotoxicosis, thyroid nodules, and thyroid cancer, as well as thyroid considerations in infertile women, fetal and neonatal considerations, and directions for future research.

“With an estimated 300,000 pregnancies impacted by thyroid disease in the United States annually, these guidelines coalesce the best available evidence into clear clinical recommendations, and will improve the health of many, many mothers and newborns alike,” say Dr. Alexander and Dr. Pearce.

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Fetal Therapy and Intervention Update

Tuesday, March 28th, 2017

By Thomas N. Trevett, M.D., Larry Matsumoto, M.D. and Michael Belfort, MBBCH, M.D., Ph.D.

Advances in technology now allow the early diagnosis of fetal abnormalities and conditions that were previously only apparent in late gestation or after birth. High-resolution ultrasonography (US) and magnetic resonance imaging (MRI) are two specific technologies that enable the evaluation and monitoring of developing organs and the detection of functional abnormalities.

Using these modalities, we can now not only diagnose anomalies, but we can also determine the ongoing effects of those anomalies and malformations on other organ systems in the growing fetus. While the malformation itself (“the first hit”) may be extremely problematic, many times the impact of the malformation on the ongoing development of other structures (“the second hit”) is even more devastating.

This understanding has led to an increasing acceptance of fetal therapy as a way to not only save the life of an affected fetus, but also to improve the post-natal functionality and outcomes in those babies that survive to birth. Examples of this include twin-to-twin transfusion syndrome (TTTS) and spina bifida.

Laser Therapy for Twin-to-Twin Transfusion

One of the first disease states shown to be amenable to prenatal surgery is TTTS, which occurs in identical twins sharing a placenta, the monochorionic (MC) placenta. TTTS presents in MC/DA twins with more easily observed signs that include excessive fluid in the sac of the recipient (polyhydramnios) and deficient fluid (oligohydramnios) in the sac of the donor, and this finding is an essential criterion for the diagnosis.

Frequently, the hemodynamic effects of TTTS are rapidly progressive, leading to heart failure in the recipient baby. Because of the open anastomoses between the two babies, if one twin dies, blood from the other baby drains into the placenta and the remaining fetus dies or suffers devastating cerebral injury. Untreated, TTTS can have a mortality rate for both babies as high as 90 percent.

Although all monochorionic twins have connections between each other on the surface of the placenta, for some (currently unknown) reason, in about 15 percent of MC twins, a net volume or pressure imbalance occurs. Through postnatal study of placentas from twins with TTTS, investigators characterized these unbalanced vascular connections and suggested that by ablating the connections in-utero, the TTTS process could be halted and even reversed.

Advances in fetoscopy instrumentation has now allowed for these anastomoses to be identified during the pregnancy as early as 16 weeks’ gestation, and by coagulating the blood within them using laser energy, flow can be stopped. Loss of one or both twins, preterm delivery, and/or severe neurologic morbidity was the norm prior to the institution of any form of therapy. Recent literature evaluating the success of laser photocoagulation of the anastomotic vessels demonstrates an 80 percent to 90 percent rate of at least one surviving twin, and a 60 percent to 70 percent rate of two surviving twins. While the procedure is invasive and carries the risk of premature rupture of the membranes (~30 percent) and preterm delivery, laser therapy is an important intervention that can significantly reduce mortality and neurologic morbidity in TTTS.

Fetal Neural Tube Defect (NTD) closure

Fetal myelomeningocele (MMC), a relatively common NTD, occurs in approximately 1 per 3,000 pregnancies and can be associated with devastating neurologic (both sensory and motor) and other functional deficiencies in survivors. Typically, function of the limbs and organs below the spinal level of the lesion is diminished.

One of the major problems with MMC is herniation of the fetal hindbrain (including the cerebellum) into the spinal canal at the base of the brain. The herniation, called an Arnold-Chiari malformation (usually type II), obstructs drainage of the CSF produced in the choroid plexi in the ventricles of the brain, resulting in progressive dilatation of the ventricles (ventriculomegaly) in utero.

Postnatally, this blocked drainage pathway results in progressive enlargement of ventricles, which impacts the size of the baby’s head (hydrocephalus), and the pressure can have permanent and serious neurologic effects including cognitive loss and neurodevelopmental delay. Shunting of the CSF from the ventricles into the abdominal (peritoneal) cavity is frequently required to decompress the growing brain.

The shunting procedure can have significant complications, and these shunts frequently require revision. Most MMCs are detected through a combination of maternal serum screening and prenatal ultrasound occurring prior to 20 weeks of pregnancy. Prenatal closure of the MMC was hypothesized as being helpful in the reduction of fetal and postnatal morbidity and mortality.

The Management of Myelomeningocele Study (MOMS) trial, published in 2011, showed clearly that prenatal closure of the defect can significantly reduce the need for shunting and at the same time improves composite neurological and motor function. The fetal surgery involved creating a 7-10 cm opening in the mother’s uterus (hysterotomy) and then carrying out and open repair of the spinal defect. This was associated with high rates of maternal and fetal complications.

Investigators have suggested that switching to a fetoscopic technique could achieve similar neonatal outcomes with decreased trauma to the uterine wall and membranes, decreasing preterm delivery rates. Very few centers have significant experience in fetoscopic spina bifida repair (one each in Germany, Spain, Brazil and the U.S.). Long-term data comparing postnatal neurologic development between the open and fetoscopic techniques is still pending, however the preliminary outcomes are very promising.

While the challenges faced by the pioneers of in-utero fetal therapy were tremendous, their vision and efforts, in concert with those of current groups, are beginning to demonstrate the potential benefits of this innovative and recently developed discipline. The available techniques are still being modified and refined to achieve improved fetal and neonatal long-term outcomes. However, despite the experimental and innovative nature of many of these techniques, outcomes for thousands of children worldwide have been dramatically improved as a result of select procedures.

Suggested Readings:

  1. Twin-to-twin transfusion syndrome: prenatal diagnosis and treatment. Benoit RM, Baschat AA. Am J Perinatol. 2014 Aug;31(7):583-94.
  2. A randomized trial of prenatal versus postnatal repair of myelomeningocele. Adzick NS, Thom EA, Spong CY, et al. MOMS Investigators. N Engl J Med. 2011 Mar 17;364(11):993-1004.
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2017 Presidential Citation – Robert Guyton, MD, FACC

Tuesday, March 28th, 2017
robert guyton md facc

Robert Guyton, MD, FACC

Robert Guyton, MD, FACC, has been awarded the 2017 Presidential Citation by the American College of Cardiology (ACC) in recognition of his contributions to the cardiovascular profession. He received the honor at the ACC’s 66th Annual Scientific Session in Washington, D.C. on March 19.

The Presidential Citation is awarded to a person whose contributions to the field of cardiology have been truly extraordinary.

“Dr. Guyton’s invaluable contributions to the field of cardiovascular medicine show unparalleled dedication to excellence and boundless commitment to improving patient care,” says ACC President Richard Chazal, MD, FACC.

“It is a privilege to be able to honor Dr. Guyton with the Presidential Citation and celebrate his contributions to and achievements in cardiovascular medicine.”

Guyton has served as chief of the Division of Cardiothoracic Surgery at Emory since 1990 and is currently the chief of cardiac surgery at Emory University Hospital. He is the Charles Ross Hatcher, Jr., Professor of Surgery and the director of the Thoracic Surgery Residency Program at Emory University School of Medicine.

Throughout his career, Guyton has held high-level offices in numerous cardiovascular societies.   He served on the Board of Directors of the Society of Thoracic Surgeons for nine years, including five years as treasurer and president in 2003-2004.  He is currently in his eighth year on the Board of Trustees of the American College of Cardiology and is entering his third year as treasurer.

Guyton was recognized, along with 2017 winners of other awards, at the ACC’s Convocation Ceremony on March 19.

The ACC is a 52,000-member nonprofit medical association established in 1949 that leads in the formation of health policy, standards and guidelines. The ACC operates national registries to measure and improve care and bestows credentials upon cardiovascular specialists who meet stringent qualifications.

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Grady Designated Show Site for Advanced Imaging

Tuesday, March 28th, 2017

In April, 2016, Grady advanced its leading position in providing innovative healthcare, when it became the first facility in metro Atlanta and one of only six hospitals in the country, to add the state-of-the-art GE Revolution 256 slice CT scanner to its imaging capabilities. As a result, Grady is now an official GE Show Site – making it a destination for other healthcare providers who want to learn more about the scanner and how it works.

The scanner, located in the Emergency Department, provides high-quality images in record time – an important plus for the city’s premier Level 1 trauma center and world renowned Marcus Stroke Center.

grady show site advanced imaging

Vice President Clinical Operations Michelle Wallace showcases Grady’s new top-of-the-line CT scanner, The Revolution

Saving time in an emergency has obvious benefits to patients, says Vice President of Clinical Operations Michelle Wallace, who talked about the amazing speed she witnessed during a recent CT scan of a stroke patient.

“It seemed like I blinked and it was done. It’s so fast. The Revolution is all about decreasing the time the patient is waiting, especially for those emergent conditions when we need to be able to find out what’s going on.”

Because of sharp image results produced by the scans, it also offers superior diagnostic capabilities, which then inform surgical planning and treatment, Wallace added.

Grady is the ideal environment to put a CT like the Revolution to work, as the hospital regularly treats a high volume of patients in need of fast, high-quality imaging. “It’s really because Grady sees everything and treats everything, we are the perfect place to utilize this technology,” said Wallace.

Because of this, Wallace expects the hospital to improve patient care in never-before-seen ways. “We’re already meeting goals, now we’re going to exceed them.”

So far, two hospitals have visited Grady to observe The Revolution in action, and staff is happy to oblige.

“We get to answer questions, show them what we do and the great work the scanner is capable of doing. We are absolutely excited to show-off,” Wallace said.

Staff traveled to Miami to learn how the equipment worked, and have adapted easily to the new technology.

“We provide high level quality care at Grady. We are known for that, we knock it out the park. It’s very nice to have the equipment to match the quality of care that our physicians, nurses and technologists provide every day. We have given them the support they need to take it to the next level,” Wallace said.

Grady has always had its eye on new innovations, and it does not plan to stop with The Revolution. Over a decade ago, Grady’s Cancer Center became home to the world’s first PET/CT scanner. 2017 will bring a brand new PET/CT with exceptional diagnostic capabilities, bolstering Grady’s position as a hospital of choice for cutting-edge healthcare.

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Alaris IV Smart Pump Technology

Tuesday, March 28th, 2017

Grady is proud to be Metro Atlanta’s first hospital to successfully integrate the Alaris IV smart pump technology with its epic electronic medical record (EMR) – taking patient safety to a new level. To date, approximately 25% of U.S. hospitals have achieved smart pump-EMR interoperability.

alaris iv system

Alaris IV Smart Pump Technology

“The ability to link programmable IV infusion pumps directly to patient medical records significantly decreases the chances of medication administration errors,” said Glenn Hilburn, Vice President, Clinical Systems, Grady Health System. “We are able to reduce the number of steps a nurse does from 21 down to three. Fewer steps means fewer chances for mistakes and greatly improved efficiency,” Hilburn added.

The smart pump-EMR interoperability rollout on March 1 was the latest step in Grady’s technology journey to improving medication administration safety. By linking the smart pump to the patient’s medical record, clinicians are able to make sure the right drug is given to the right patient, within the right dose, and at the right time.

“The system validates the infusion against the physician’s order through barcode technology and programs the pump to dispense the medication. In addition, it sends data back to the medical record as the patient receives the infusion, providing important, real-time information for the patient care team,” Hilburn said. “This interoperability is recognized throughout healthcare as a best practice.”

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New Northside Hospital Cherokee to open May 6

Tuesday, March 21st, 2017

Northside Hospital Cherokee’s long-awaited replacement hospital will open for patients on Saturday, May 6, 2017.

The new hospital is located at 450 Northside Cherokee Boulevard in Canton, off I-575 at the Ga. Hwy 20 exit.

“This is a huge move forward for Cherokee county and the surrounding areas,” said Billy Hayes, CEO of Northside Hospital Cherokee. “Our new hospital is the culmination of a lot of hard work by many people over many years. The entire Northside Cherokee family is proud of what we’ve accomplished, and we look forward to a new era of health care service.”

northside hospital cherokee concept

Northside Hospital Cherokee Concept

Construction is complete on the new hospital, which will open with 105 inpatient beds and more than twice the square footage as the current hospital. Northside staff is now focused on training and education, while overseeing the installations of equipment and furniture.

A medical office building opened on the 50-acre campus in early January. Several physician practices and Northside Hospital Radiation Oncology have opened their offices and are seeing patients. Additional Northside services and physicians will move into the building over the next several months.

Northside is planning an open house for late April to give everyone a chance to tour the new hospital campus before patients are moved and accepted there on May 6.

For more information about the new hospital and to view videos of the construction, visit Northside Cherokee.

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MAA Dinner Meeting: GPS Cancer and Advances in Precision Medicine

Thursday, March 23rd, 2017

March 23 at 103 West, Atlanta. For more information, visit Medical Association of Atlanta.

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The American Academy of Allergy, Asthma and Immunology Annual Meeting

Friday, March 3rd, 2017

March 3-6, 2017, Atlanta History Center, Atlanta. For more information, visit AAAAI

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Emory’s 11th Annual Celebration of Technology and Innovation

Thursday, March 2nd, 2017

March 2, 2017, Office of Technology, Emory Conference Center, Atlanta. For more information, visit Emory Technology

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