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Archive for the ‘Profiles’ Category

Spotlight on Hepatitis C

Wednesday, October 29th, 2014

By Helen K. Kelley

From ATLANTA Medicine, Vol. 85, No. 4

Lance Stein, MD

Lance Stein, MD

Hepatitis C, the most common blood-borne infection in the United States today, is considered a public health threat. From new medications just entering the market and clinical trials to educational efforts and a push for identifying those who have the infection, hepatitis C is a hot topic among medical practitioners in Atlanta and elsewhere.

Baby Boomers at risk; new meds have unprecedented success

Hepatitis C is most prevalent in the Baby Boomer generation – those born between 1945 and 1965 – many of whom are asymptomatic and don’t yet know they have the infection. Roughly three-fourths of the current population is now aging and falling into the targeted bracket for having the infection, according to Lance Stein, M.D., a transplant hepatologist at Piedmont Transplant Institute.

“Age is important. If you are infected with hepatitis C, it can do significant damage to the liver … and it actually takes approximately 30 years for that to happen in most patients. So, let’s say if a person was infected in 1970 and is now turning 65, that’s when we’ll begin seeing the problems,” he explains. “Hepatitis C has become a big public health issue. This is why there’s been a huge increase in the establishment of liver cirrhosis clinics and transplant clinics.”

Stein adds that the uptick in patients identified as having hepatitis C just happens, fortunately, to coincide with helpful advances in medicine.

“Hepatitis C has been ‘blowing up’ in terms of new treatment options. These new drugs are much more effective than older treatments like Interferon and Ribavirin, both of which carry significant side effects. But the new treatments are also much more expensive,” he says.

According to Stein, sofosbuvir (Solvadi), which was approved by the FDA in December 2013, is priced at about $84,000 for a three-month treatment. That equates to roughly $1,000 per day. However, the drug has been highly successful to date, with an approximate 89 percent cure rate in people with hepatitis C type 1. Stein says that the high cost upfront may actually end up saving patients and insurers money in the long run.

“The higher cure rate of sofosbuvir, along with fewer side effects than previous treatments, means fewer doctor visits and lab tests than previously required on a regimen like Interferon. It may also prevent the need for a transplant in the future,” he notes. “Some even newer drugs are currently awaiting approval later this year. This is exciting because clinical trials show cure rates for these new treatments are almost 100 percent after a three-month regimen.”

Aasim M. Sheikh, M.D., who specializes in the treatment and management of liver diseases as a gastroenterologist, hepatologist and clinical researcher with GI Specialists of Georgia, agrees that the new drugs hold great promise for people infected with hepatitis C.

Enrique Martinez, MD

Enrique Martinez, MD

“The envelope is being pushed,” he says. “Researchers – big players like Merck, Gilead, Johnson and Abbott – are looking for regimens that combine drugs to result in a minimum number of pills with the fewest side effects and shortest treatment.”

Sheikh adds that there are four different classifications of drugs that are proving to work well in combination.

“These drugs block the hepatitis C virus at different points, shutting down different enzymes that help the virus multiply,” he explains. “Together, they have a synergistic effect in controlling the virus.”

Sheikh states that the most important keys to treating and curing hepatitis C are: identifying people who have the infection; prioritizing and treating those who have the most advanced disease; the development of more effective treatments of shorter duration and fewer side effects; and analyzing the results of various treatment protocols.

“The more people we treat, the more we find out,” he says. “We hope to alter the course of their illness and keep them at a lower risk for further complications.”

Enrique Martinez, M.D., a gastroenterologist and hepatology specialist with Atlanta Gastroenterology Associates, has watched the progression of hepatitis C treatments since he began practicing in 1989.

“This is a very exciting time. It’s amazing when you consider that a disease with only an 8 percent cure rate 25 years ago is now approaching a 100 percent cure rate,” he says. “And it’s interesting that today we consider treatments with a less than 95 percent cure rate to be inferior. Pharmaceutical companies are constantly looking at new combinations of drugs that could result in better and better cure rates for hepatitis C patients.”

Martinez adds that the evolution of drug combinations also holds great promise for special populations with hepatitis C.

“People we previously thought could not be treated for hepatitis C are now being considered possible candidates for the new drug regimens,” he says. “These populations include people with immune disorders such as lupus and rheumatoid arthritis, sickle cell disease or colitis. Even people who must undergo dialysis or who are pre- or post-transplant patients have new hope for treatment.”

Lesley Miller, MD

Lesley Miller, MD

Providing care to an underserved population

The Grady Liver Clinic at Grady Memorial Hospital, established in 2002, is an innovative model for expanding access to hepatitis C care for urban, underserved patients. This population is disproportionately affected by the infection. Dr. Lesley Miller, the clinic’s medical director, says the facility is a unique and revolutionary model because it is run and staffed by general internists (rather than specialists), who work together to provide hepatitis C management – including antiviral treatment – to patients regardless of their insurance status.

“Patients without options for specialty care really benefit from this clinic,” Miller says. “We do a lot of education and counseling, and we provide immunizations against hepatitis A and B, evaluation of liver disease and medical comorbidities, and treatment options. We’re one of the only places [in Atlanta] that can offer these services to people who don’t have health insurance.”

A study of the Liver Clinic’s population for its first five years of operation showed that it was primarily African American (76 percent) and uninsured (59 percent). Patients had difficult-to-treat characteristics, including genotype 1 hepatitis C (90 percent), advanced liver fibrosis (28 percent), and high viral loads. Sixty-seven percent had comorbid medical conditions, and 40 percent had psychiatric disease. Fourteen percent of patients were treated for hepatitis C during the study period.

With those early statistics in mind, Miller is pleased with the medical advances that have made hepatitis C treatment easier for the Clinic’s current patients and is excited about the speed at which new treatment options are progressing.

“It’s unbelievable how fast the research and development in the world of hepatitis C are changing. Things I was doing last month are already different,” she says. “More of our patients are now candidates for treatment than have been in the past, because treatment duration is shorter and the regimens are easier or more relevant for people who have other chronic health problems. It’s gratifying to give patients a regimen that’s not going to make them sick and has a high probability of curing them.”

The stats on hepatitis C

In the National Health and Nutrition Examination Survey (NHANES), conducted between 2003 to 2010, researchers studied people with hepatitis C in order to estimate the prevalence of chronic HCV infection and to identify factors associated with the condition. The survey included interviews and testing of serum samples from participants aged six years and older.

Based on 273 participants who tested positive for HCV RNA:

• The estimated prevalence of HCV infection was 1.0 percent (95 percent CI, 0.8 percent to 1.2 percent), corresponding to 2.7 million chronically infected persons (CI, 2.2 to 3.2 million persons) in the U.S. non-institutionalized civilian population.

• Infected persons were more likely to be aged 40 to 59 years, male, and non-Hispanic black and to have less education and lower family income.

• Factors significantly associated with chronic HCV infection were illicit drug use (including injection drugs) and receipt of a blood transfusion before 1992; 49 percent of persons with HCV infection did not report either risk factor.

Based on the data collected, researchers estimated that approximately 2.7 million U.S. residents in the population sampled by NHANES have chronic HCV infection. The study highlighted the continued urgency of identifying the millions of persons who remain infected and linking them to appropriate care and treatment.

In the news

According to a recent article in The New York Times, “sales of the new hepatitis C drug Sovaldi reached $3.5 billion in the second quarter, a huge figure that puts it on track to become one of the world’s best-selling medicines but could intensify concerns about society’s ability to pay for it.”

The FDA-approved drug, manufactured by Gilead Sciences, is for patients with hepatitis C virus (HCV) genotypes 1, 2, 3 or 4 infection.

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New Breast Cancer Treatment Options Boost Survival, Offer New Hope

Wednesday, September 24th, 2014

By Anita Johnson, M.D.

As a surgical oncologist focused on treating breast cancer, I see daily how devastating a breast cancer diagnosis can be. But I also see daily how new and often cutting-edge treatments give women the hope and courage they need to help manage or overcome the physical, mental and emotional challenges of breast cancer, and in many cases, beat the disease altogether.

One in eight women will develop breast cancer in her lifetime. While the leading risk factors are well known – older age, family history, mutations in certain genes – the most important risk factor for breast cancer is simply being a woman.

The fact that any woman can develop breast cancer is one reason annual mammograms and clinical breast exams are so important; regular screening helps detect cancer early. As with every type of cancer, when breast cancer is discovered early there are more treatment options available, survival rates are longer and the cure rate is higher.

In the U.S., trends in breast cancer are encouraging. Data from the National Cancer Institute (NCI) show consistent declines in both new cases and deaths from breast cancer since 1990. Further, the U.S. Centers for Disease Control and Prevention (CDC) reports that from 2001 to 2010 the incidence of breast cancer among U.S. women did not increase, while mortality decreased 2 percent annually.

What’s most notable about these data is that breast cancer mortality is decreasing faster than incidence – meaning that women with breast cancer are living longer. That trend also is borne out by NCI data: although only 75 percent of women with breast cancer survived more than five years in 1975, in 2011 more than 90 percent did.

There may be several reasons behind the decline in breast cancer deaths. However, new technologies and improvements in existing treatments are very likely contributing to higher survival rates and improved quality of life for women with breast cancer.

For example, a new technology called the MarginProbe System helps surgeons determine if cancer cells are present in the margins of tissue that has been removed. The technology helps reduce the rate of second surgeries following lumpectomy. In addition to continued refinements in breast-conserving and reconstructive oncoplastic surgery techniques, there is an array of advanced treatment technologies available today.

Genomic testing is an innovative new diagnostic tool that allows tumors to be examined on a genetic level. By identifying mutations that occur in a cancer cell’s genome, doctors can better understand what caused the tumor and tailor treatment based on these findings. Genomic testing might suggest a drug normally used for another type of cancer could be an appropriate treatment for breast cancer based on the genetic properties of the tumor.

Another example is intraoperative radiation therapy (IORT), one of many new technologies that deliver radiation more precisely, helping minimize damage to healthy tissue and treatment times. With IORT, radiation is delivered directly to the tumor site after a surgeon has removed the tumor. A 30-minute dose of IORT can often replace weeks of traditional radiation.

In addition to radiation, there have been numerous advances in chemotherapy treatments for breast cancer. Targeted therapy blocks specific molecules involved in tumor growth by directing drugs or other specially-created compounds (e.g., man-made immune system proteins) to attack cancer cells. A targeted therapy called chemoembolization delivers medication through a catheter directly into a tumor using image guidance. The chemotherapy drugs are mixed with particles, called microspheres, which block blood flow to the tumor.

With so many options available to treat breast cancer today, treatments can almost be tailored to the individual based on factors such as her genetic profile, location of the tumor, the type of tumor and whether the cancer has spread, among others. However, which treatment a woman ultimately chooses is a very personal decision best made in collaboration with her family, personal physician and oncologist.

The specter of breast cancer can be frightening, but it is important to remember that most women will not develop the disease. Women who are at an increased risk should talk to their doctors about how often they should receive mammograms and what other screenings, such as genetic testing, might be beneficial. Although breast cancer continues to claim too many lives – more than 40,000 this year – advanced treatment options are having a significant impact on survivability and quality of life.

Anita Johnson, MD, FACS, is medical director of breast surgical oncology at Cancer Treatment Centers of America at Southeastern Regional Medical Center in Newnan, Ga. 

 

 

 

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Understanding the Immune Response

Tuesday, December 11th, 2012

by Gary E. Myerson, M.D., F.A.C.R.

From ATLANTA Medicine, 2012, Rheumatology, Vol. 83, No. 3

Gary E. Myerson, M.D.

Gary E. Myerson, M.D.

Centuries ago, geography itself served as the primary barrier to disease exposure. But man’s exploration of the planet, enhanced by progressive technological expertise, has permitted both exposure to and expansion of diseases worldwide. However, our increasing knowledge of science overall and the specific components of the immune response has led to numerous diseases either being reduced or eliminated.

The immune response is an ancient system. Certain components, however, have not significantly changed in the millions of years of existence of species with vertebrae. The homo-sapiens and homo-erectus, nearly 250,000 years ago, possessed an immune system similar to ours. Innate immune response has been present throughout this entire period. It has been our “equalizer” in dealing with the microscopic environment that envelops us. We have made” friends” with many microbes, resulting in relationships that are symbiotic, while others are indeed antagonistic or parasitic. It is this inherent, genetically provided, innate response that is our defense against invaders both physically and chemically. The Adaptive or acquired immune response, our body’s ability to develop antibodies, has allowed us to improve or enhance our own innate immune response. Biologic therapy with monoclonal antibodies now allows us to manipulate specific proteins important in the immune response.

Our first line of defense includes the skin and lining surfaces of the internal body organs. There are enzymes in body secretions including lysozymes, phospholipases and defensins, which disrupt cell membranes promoting cell death. Periodically, the anatomical barriers are penetrated and an “acute inflammatory reaction” follows. The release of acute phase reactants: transferrin, CRP, interferon and interleukins, results in the cardinal signs of inflammation: calor/hot, rubor/red, dolor/painful and tumor/swelling.  The phagocytic cells including the neutrophils, macrophages, dendritic cells, natural killer or NK cells and eosinophils are the major players in identifying and responding to microscopic invaders. The phagocytic cells are directed to specific locations via cytokines, protein communicators of inflammation that identify, engulf and destroy pathogens.

These cells are primary players of the innate immune response – the oldest form of the host defense system. The innate immune response is triggered when microbes
(bacteria, virus and fungi) are detected. On or attached to the cell membranes of pathogens are commonly shared patterns (PAMPS). These include lipopolysaccharides(LPS), lipoteichoic acid, flagellin, RNA of viruses, amongst others. These molecules are recognized by receptors on the phagocytic cells called pattern recognition receptors (PRR).

One large group of the PRRs is a specific subgroup entitled Toll-like receptors (TLR). These highly specific receptors, numbered 1 through 13, identify and bind PAMPS, resulting in cytokine production triggering inflammation.

The complement cascade is also a major component of the innate immune response. The Complement system serves as an identifier and clearing house of pathogens by promoting vascular permeability, recruitment of phagocytic cells and ultimately the opsonization of bacteria and immune complexes. Opsonization refers to the coating and subsequent marking of bacteria for future destruction.

A large component of opsonization occurs in the spleen, which is why splenectomized patients particularly need vaccinations. Complement CH50 is a measure of total complement activity. Individuals with active autoimmune disease may have low levels of C3 and C4 due to  overactivity of the complement cascade.  This results in immune complex formation and the consumption of complement.

When the inflammation resolves, complement levels return to the normal range. Therefore, low levels of CH50 and C3 and C4 reflect active autoimmune disease, but higher levels do not.

Innate immune response is a non-antigen specific, immediate reaction. It does not produce immunological memory. For long-term protection, there is our adaptive or acquired immune response. Immunological memory is accomplished by the development of antibodies as our ready reserve defense force. Subsequent encounters with the same organism result in an enhanced response. There is a period of approximately 10-14 days for antigen-specific antibodies to be developed.

All cells of the immune system have their origin in the bone marrow. The myeloid series primarily produces the cells of the innate immune system including the neutrophils, monocytes and dendritic cells.  While the lymphoid series(lymphocytes) produces cells for the acquired or adaptive immune response, the T cells undergo differentiation into their distinct types under the influence of the thymus gland. B cells become mature in the lymph nodes and the spleen.

There is a tremendous amount of interaction between both systems, utilizing the myeloid series innate immune system for stimulation and activation of the acquired immune response. T-cells are involved in the cell-mediated immune response. They have no cytotoxic activity and do not kill infected cells or clear pathogens directly. Instead, they control the immune response by directing other cells to perform these tasks.

The cytokines the T-cells produce are the “protein communicators of inflammation.” Three important cytokines include TNF alpha and interleukins IL-1 and IL-6. These have been identified as primary players in autoimmune diseases including rheumatoid arthritis, psoriasis and psoriatic arthritis, Ankylosing spondylitis and inflammatory bowel disease(specifically Crohn’s disease) as well as Uveitis and Sarcoidosis.The T-cell begins as a “naïve” cell, which requires antigen presentation in order for it to become activated. These antigen-presenting cells (APC) include the macrophage, dendritic cell and the B cell.  The APC presents the antigen to the naive T-cell via its major histocompatibility complex (MHC) T-cell receptor (TCR). Depending on the APC cell type and the predominance of surrounding cytokines, T-cells differentiate in one of four directions:

1. TH 1 cells. APCs include the macrophages and dendritic cells. IL 12 and interferon (INF) gamma are the cytokines that drive differentiation. This type of T-cell usually develops from exposure to intracellular bacteria, fungus or viruses.

2. TH 17 cells. Neutrophils; IL 23, IL-1, IL-6. Usually from exposure of extracellular bacteria and fungi.

3. TH 2 cells. Eosinophils and basophils. IL-4. Usually from exposure to parasites.

4. T reg (regulatory) cells. Response to self-antigens. IL-10 and TGF beta. Down regulates autoimmune response.  There is however cross stimulation and inhibition
depending on which interleukin predominates. For instance, IL6 inhibits TGF beta, therefore driving TH 17 production and reducing T reg production, Alternatively, IL-4 while driving TH2 production inhibits TH 17 production.

Cell membranes of T-cells have cluster differentiation (CD) glycoproteins CD4 and CD8. Cells with the CD4 glycoprotein are referred to as helper cells, and those with
CD8 glycoprotein are referred to as cytotoxic T-cells. CD4 helper cells assist in the maturation of B cells into plasma cells and memory B cells. They also assist in the activation of cytotoxic T-cells and macrophages. Cytotoxic CD8 cells destroy viral-infected and tumor cells and also play a role in transplant rejection.

The humoral immune response is directed by B lymphocytes (B cells) differentiating into plasma cells which produce antibodies. The B cell develops through several stages. A B cell begins as a progenitor cell, then progresses to a pro-B cell and finally a pre-B cell. At this point, it leaves the bone marrow to mature in the lymph nodes and spleen where it becomes exposed to the pathogenic environment. As it matures, it develops three surface receptors – Blys, TACI and the B-cell receptor (BCR). When these receptors are bound, the cell matures and continues to exist. Failure to bind these receptors results in apoptosis or programmed cell death. This has become a recent important discovery since Benlysta, a new drug for the treatment of lupus, works by inhibiting Blys, the cell surface receptor.

These immunoglobulins are a hallmark of our defense system. We’re aware that deficiencies in any one of them or their subtypes results in the development of recurrent infections. Specific types of intravenous and subcutaneous gammaglobulin are available for those deficiency states. Memory B cells are formed from activated B cells that are specific to the antigen encountered during the primary immune response. These cells are capable of living “a long time” and can respond quickly following a second exposure to the same antigen.

B-1 cells and B-2 cells, B-1 cells express high levels of IgM greater than IgG and
are polyspecific – meaning that they have the ability to produce low-level response to many antigens.

Unlike the T cell, the B cell does not need the antigen presented to it. It recognizes the antigen in the blood or lymphatic system and engulfs it. It can then act as an antigen-presenting cell itself by displaying its antigen bound to its unique MHC on the cell surface allowing a T-cell to bind to it. Through a co-stimulatory mechanism necessitating a second binding site to be activated, cytokines can then be released. The cytokines released by that T-cell further propagate the B cell into its mature state, producing plasma cells and more immunoglobulin. Antibodies bind to their specific antigens forming immune-complexes. These complexes are then “cleaved” by the complement system and eliminated through the reticuloendothelial system.

Autoimmune diseases result from aberrant antibody production. These autoantibodies are actually produced on a regular basis by all individuals. Fortunately, more than 90 percent of them undergo spontaneous apoptosis and never progress. Anti-B cell medications predominantly work by interfering with the B cell during its maturation. Examples of these medications are being utilized in both oncology and rheumatology.

A baby’s immune defenses are passively transferred from the mother at birth. The baby’s own immune defenses take approximately three months to begin to function.

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In Terms of Vascular Age, 50 May Really Be the New 60 for Women

Wednesday, November 14th, 2012

By Kimberly P. Champney, M.D., MSCR

From ATLANTA Medicine, 2012, Women’s Health, Vol. 83, No. 1

National public awareness campaigns for heart disease in women from the American Heart Association and other organizations have seen initial success. Between 1997 and 2006, the number of women recognizing that the leading cause of death among women is heart disease increased from 30 percent to 55 percent (1). Along with this increased knowledge, women have seen a decline in deaths secondary to cardiovascular disease. However, areas of concern still remain. For example, women know that cholesterol is an important risk factor for cardiovascular disease, but few women know their own personal cholesterol levels and other risk factors (1).

“Fifty is the new forty” is a common phrase heard today, especially as many famous women such as Oprah Winfrey, Christie Brinkley, Madonna and Sharon Stone approach or have turned 50. However, in terms of vascular age, 50 may really be the new 60 for women. For example, a 51-year-old teacher with a family history of heart disease reports good health. She feels well, is currently enrolled in Weight Watchers at work that meets twice a week. Her blood pressure is 140/82, total cholesterol 220mg/dL, HDL 34 mg/dL, LDL 145 mg/dL, and triglycerides are 198 mg/dL. She would like to know if she needs to take a statin, as prescribed by her primary care physician. She is 5’1”, weighs 147 lbs, body mass index (BMI) 27 and has a waist circumference of 37 inches. This 51-year-old lady is clearly not the “new forty” and in fact has a coronary artery calcium score of 25 estimated vascular age of 63. Vascular age can be calculated using data from the Multi-Ethnic Study of Atherosclerosis(MESA) knowing age, gender, cholesterol values, blood pressure and use of tobacco (3).

While this particular patient is not the “new forty,” epidemiologic data suggest that she is a more representative 50-year-old female today. Two out of every three women in the U.S. are overweight or obese, one out of three women will have high blood pressure, almost one in two will have elevated cholesterol, and less than one third of women report regular physical activity. By the age of 50, 40 percent of women will have one cardiovascular risk factor and 17 percent of women will have two or more traditional risk factors (2).

Heart Disease in Young Women

Despite the overall improvement in heart disease awareness and mortality among women, there is a slight increase in heart disease death rates seen in young women, ages 35-54 years. This trend “may represent the leading edge of a brewing storm (3).” We also know that it is younger, not older women, who have higher risk of death after myocardial infarction relative to men (4). This increase in cardiovascular mortality among young women is likely linked to obesity and the cardiovascular risk factors associated with obesity. Particular attention to cardiovascular risk should be given to women in this younger age group.

Cardiovascular Disease Among Minority Women

Racial disparities in healthcare are evident among many diseases, and this is of particular importance in Atlanta given the diverse population. Black women, particularly in southern states, have the highest incidence of uncontrolled hypertension, obesity, sedentary lifestyle and dyslipidemia. This combination of uncontrolled risk factors leads to increased mortality among minority women, particularly black women. Among young women, ages 45-64, with a first myocardial infarction, 18 percent of non-Hispanic white women will die within five years. More alarming is that among that same younger age group, 28 percent of black women will die within five years after a first myocardial infarction. This racial disparity among women is not as great among older women. This is a cause for concern because it is the younger age minority women at greatest mortality risk (2).

Identifying Cardiovascular Risk in Women

All women should have their cardiovascular risk classified by their provider as high risk, at risk, or ideal cardiovascular health. Along with appropriate risk stratification, providers must make it a priority to educate each woman regarding their personal cardiovascular risk factors and overall risk for future cardiovascular disease.

Pregnancy: A Unique Opportunity to Estimate a Woman’s Future Risk

The short-term risk to both mother and baby of preeclampsia and gestational diabetes is well understood. However, we are now learning that these pregnancy complications have long-term risk as well. Pregnancy is an early metabolic and cardiovascular “stress test” for many women. Women with a history of preeclampsia have a twofold increased risk of ischemic heart disease, stroke or thromboembolic event in the five to 15 years following pregnancy (6). Pregnancy can unmask endothelial and metabolic dysfunction early in life, and obstetricians should not miss this opportunity to intervene early on these at-risk women. Postpartum, women with preeclampsia and gestational diabetes should be referred to a primary care provider or cardiologist for risk factor modification (5).

Early Intervention on Future Cardiovascular Risk

While cardiovascular disease typically does not manifest until the fifth or sixth decade in life, it is well known that atherosclerotic process begins in the second and third decades. Despite this knowledge of the atherosclerotic process, risk factor modification is typically not emphasized early enough. Clinical trials have shown a 30 percent reduction in cardiovascular events when statins are started in patients age 50 to 60. Initiating statin therapy at age 30 may prevent 60 percent of cardiovascular events when initiated early in the disease process and outcomes measured over a lifetime rather than the standard five years in most clinical trials. Primordial prevention (prevention of risk factors) and early risk factor modification need to be a primary focus for medical providers.

In summary, significant improvements in the awareness and treatment or heart disease in women have been made. However, heart disease remains the leading cause of death for women. The increasing rates of obesity and heart disease in young women raise concern about the future of women’s health. Health care providers need to identify and intervene on women with cardiovascular risk factors early, making special note of high-risk subgroups like black women. Pregnancy complications such as preeclampsia and gestational diabetes should be viewed as a “failed metabolic stress test” and serve as an early warning sign of potential risk both to patients and their obstetric provider.

References
1. Mosca L, Mochari H, Christian A, et. al. National Study of Women’s Awareness, Preventive Action, and Barriers to Cardiovascular Health. Circulation 2006; 113:525-34.
2. American Heart Association. Heart Disease and Stroke Statistics – 2012 Update. Circulation. 2012:125:e2-220.
3. McClelland RL, Chung H, Detrano R, et. al., Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2006;113:30-7.
4. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the US from 1980 through 2002. J Am Coll Cardiol. 2007;50:2128-32.
5. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholtz HM. Sex-Based Differences in Early Mortality after Myocardial Infarction. N Engl J Med. 1999;341:217-225.
6. Mosca L, Benjamin EJ, Berra K, et. al., Executive Writing Committee. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update. J Am Coll Cardiol. 2011;57:1404-23.
7. Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2001;335:974.
8. Steinberg D. Earlier Intervention in the Management of Hypercholesterolemia: What Are We Waiting For? J Am Coll Cardiol. 2010;56:627-29.

Kimberly P. Champney, M.D., MSCR  is a cardiologist at Northside Hospital. She received her medical degree from the Medical College of Georgia and her Masters of Science in Clinical Research from Emory University. She has been at Northside Hospital since August 2007. Her interests are in preventive cardiology, women and heart disease, pulmonary hypertension, and cardiac imaging. Dr. Champney is a member of the American Heart Association and a Fellow of the American College of Cardiology.

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Mahmoud Barrie, M.D., Discusses Barrett’s Esophagus: An Update on New Developments

Tuesday, May 29th, 2012

By Mahmoud Barrie, M.D.

From ATLANTA Medicine, 2012, Gastroenterology, Vol. 82, No. 4

Barrett’s esophagus continues to be an evolving condition due to continued improvements in the areas of definition, pathophysiology, surveillance, diagnosis and therapeutic options.

Definition

The definition of Barrett’s esophagus in the United States has remained relatively unchanged as “salmon colored mucosa at the distal esophagus on endoscopy and evidence of intestinal metaplasia in the squamocolumnar junction on histology.” However, the British Society of Gastroenterology (BSG) defines Barrett’s esophagus as “an endoscopically apparent area above the esophagogastric junction that is suggestive of Barrett esophagus [salmon-colored mucosa], which is supported by the finding of columnar lined esophagus on histology,” suggesting that the presence of intestinal metaplasia is not a requirement. The BSG definition takes into account the absence of intestinal metaplasia due to sampling errors and the development of cancer in the absence of intestinal metaplasia. This definition, however, potentially increases the number of patients with the disease.

Pathophysiology

The mechanism of metaplasia in Barrett’s esophagus has not been well established. Mucosal injury from acid reflux is believed to be a prerequisite to its development, however, other factors — such as increased mucosal permeability — must be involved because not all patients with acid reflux develop Barrett’s esophagus.

Furthermore, a study by Fletcher et al. has revealed the formation of a pocket of highly acidic area at the gastroesophageal junction, which converts dietary nitrates to mutagenic Nitric oxide within the pocket, as a potential pathway to developing Barrett’s esophagus with dysplasia.

Surveillance and Risk Assessment

Despite the development of the Prague C and M (C=circumference and M=maximal length of Barrett’s, including tongues) classification of Barrett’s esophagus, only Prague M is used with any degree of consistency. A Barrett’s esophagus > 3 cm in length has been shown to increase the risk of development of dysplasia or adenocarcinoma.

Additionally, the question of who needs surveillance continues to evolve. White males older than age 50 with long-term dyspepsia were thought to be highest risk group. However, the new American Gastroenterological Association (AGA) guidelines suggest screening for Barrett’s esophagus in patients with multiple risk factors (such as being white, male and age 50 or older, and having elevated body mass index, diabetes, truncal obesity, chronic dyspepsia and/or hiatal hernia). There is no suggestion of the minimal number of risk factors required, but it is implied that screening is no longer limited to 50-year-old Caucasian males with chronic dyspepsia. The number of biopsies and the timing of surveillance endoscopy also have changed, perhaps to reflect the low incidence of adenocarcinoma (0.2% to 3.5% per year) and the cost of surveillance.

Most experts, including the AGA, recommend taking four quadrant biopsies every 2 cm in nondysplastic Barrett’s esophagus patients, but every 1 cm Barrett’s esophagus continues to be an evolving condition due to continued improvements in patients with known or suspected dysplasia. The endoscopic surveillance interval has been increased to every three to five years for nondysplastic Barrett’s esophagus patients and every six to 12 months for patients suspected of having dysplasia. For high-grade dysplasia without option of eradication, surveillance endoscopy every three months is recommended.

New Diagnostic Tools

Diagnosis of Barrett’s esophagus relies heavily on biopsy samples obtained from endoscopy. Thus, the ability to endoscopically identify Barrett’s esophagus with or without dysplasia will determine accuracy of the biopsies and, ultimately, the benefits of surveillance. New developments in enhanced imaging techniques — such as narrow band imaging (NBI), chemoendoscopy, confocal laser microscopy (CLM) and autofluorescence imaging (AFI) — are proving to be great assets.

NBI produces high-resolution images of the mucosa to help identify pre-malignant or malignant areas on the basis of irregular mucosal pattern. While CLM provides information at the cellular level during ongoing endoscopy, AFI uses blue light to detect fluorescence from biological tissue. However, the AGA guidelines do not currently support these techniques in the routine diagnosis of Barrett’s esophagus.

Therapeutic Options

The cornerstone for the treatment of Barrett’s esophagus is acid reflux therapy because mucosal injury from acid reflux is believed to be a prerequisite for the development of Barrett’s esophagus. It is important, however, to recognize that there are no prospective trials confirming that control of acid reflux prevents Barrett’s esophagus or cancer.

Multiple endoscopic techniques have developed for the management of Barrett’s esophagus with or without dysplasia. These include thermal techniques (multipolar electrocoagulation, argon plasma coagulation, heater probe, laser and radiofrequency ablation [RFA], and neodymium-doped ytrium aluminium garnet [ND:YAG]) and nonthermal techniques (photodynamic therapy, endoscopic mucosal resection [EMR] and cryotherapy). In a multicenter, randomized, sham-control trial by Shaheen et al, RFA was shown to produce complete eradication in 81% of patients with high-grade dysplasia and an overall complete eradication of intestinal metaplasia in 77.4% of patients — compared to 19% and 2.3%, respectively, in the control group.

Furthermore, eradication was observed in 90.5% of patient with low-grade dysplasia as compared to 22.7% in the control group. The risk for disease progression was also shown to be statistically lower in the RFA group compared to control. Therefore, RFA has emerged as the standard of care for flat lesions associated with Barrett’s esophagus with dysplasia and EMR is advocated for raised nodules.

Conclusion

Barrett’s esophagus is an evolving field with recent developments that are aimed at improving its diagnosis, surveillance and therapy. The incorporation of these new developments into daily practice will be gradual and deliberate with the ultimate goal of preventing esophageal adenocarcinoma due to Barrett’s esophagus.

References

Shaheen, N et al. Radiofrequency Ablation in Barrett’s Esophagus with Dysplasia. NEJM 2009 May 28;360(22):2277-88.

Playford, R. J. New British Society of Gastroenterology (BSG) guidelines for the diagnosis and management of Barrett’s esophagus. Gut 55, 442 (2006).

Chiu, P. W. et al. Esophageal pH exposure and epithelial cell differentiation. Dis.
Esophagus 22, 596–599 (2009).

Dvorak, K. et al. Expression of bile acid transporting proteins in Barrett’s esophagus and esophageal adenocarcinoma. Am. J. Gastroenterol. 104, 302–309 (2009).

Wang, C., Yuan, Y. & Hunt, R. H. Helicobacter pylori infection and Barrett’s esophagus: a systematic review and meta-analysis. Am. J. Gastroenterol. 104,
492–500 (2009).

Wang, K. K. & Sampliner, R. E. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am. J. Gastroenterol. 103, 788–797 (2008).

Badreddine, R. J. & Wang, K. K. Barrett esophagus: An update. Nat. Rev. Gastroenterol. Hepatol. 7, 369–378 (2010).

Harrison, R. et al. Detection of intestinal metaplasia in Barrett’s esophagus: an observational comparator study suggests the need for a minimum of eight biopsies. Am. J. Gastroenterol. 102, 1154–1161 (2007).

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Cesarean Section: A Look Back…and Forward

Thursday, May 3rd, 2012

By Kirsten Franklin, M.D., FACOG

From ATLANTA Medicine, 2012, Women’s Health, Vol. 83, No. 1

Cesarean section has been around for hundreds of years but not without serious consequences for the mother. Originally the procedure was used postmortem to satisfy religious and cultural requirements that the dead infant be buried separately from the mother. There are early reports of its use as a last resort to attempt to save the woman’s life, but historical record of success in this arena is absent. The first written record of a live birth and living mother after cesarean delivery originates from Switzerland in 1500. There is some question regarding the accuracy of the story, but it has been reported that a sow gelder, Jacob Nufer, was granted permission by local authorities to attempt the procedure after his wife spent several days in labor and was unable to deliver despite help from 13 midwives. The child lived to the age of 77 and his mother subsequently delivered five more children, including a set of twins, via vaginal birth.

Although the sixteenth and seventeenth centuries brought numerous works of art illustrating human anatomy in detail, it was not until the mid to late 1800s that human cadavers were available to medical students and practical experience allowed physicians to gain a true understanding of anatomy. Thereafter, cesarean sections were attempted in greater numbers. Until then, unsuccessful deliveries had been treated via craniotomy and a mutilating extraction of the fetus through the vagina in an effort to save the mother’s life. When ether was used for the first time in 1846 at Massachusetts General Hospital by dentist William T.G. Morton during surgery to remove a facial tumor, the future of cesarean section (and surgery as a whole), changed dramatically. There was initial reluctance to use anesthesia in obstetrics based upon the concept that women should suffer during childbirth to atone for Eve’s sin. However, once Queen Victoria was administered chloroform for the births of two of her children in 1853 and 1857, widespread acceptance of anesthesia for childbirth took hold.

Initial mortality rates for cesarean section were high. Germ theory was introduced in the mid 1860s but was not widely accepted. Physicians and hospital staff did not wash hands between patients and wore street clothes to operate. Additionally, surgeons did not suture the uterine incision for fear that the sutures would cause infection and promote uterine rupture in future pregnancies. Adherence to this theory resulted in high maternal death rates from hemorrhage and infection. For a brief time, hysterectomy in conjunction with cesarean was used to decrease those rates. Once Max Sanger’s monograph advocating silver sutures to close internal wounds was widely circulated in 1882, confidence in the procedure increased and hysterectomy was abandoned.

The more modern low cervical uterine incision was popularized by British obstetrician Munro Kerr in the early 20th century, and the surgical details were further refined after the widespread availability of penicillin in the 1940s. Population growth in the cities and the trend toward medical management of pregnancy in the 1940s led to a boom in growth of women’s hospitals. In 1938, about half of births in the United States were taking place in hospitals, rising to 99 percent by 1955. In 1965, the cesarean section rate was 4.5 percent.

Over the past 40 years, cultural shifts have changed the focus of obstetrics. Paternal involvement in the delivery process, the advent of fetal monitoring in the early 1970s, and the assessment of fetal development with ultrasound have led to a major shift in perspective. The delivery process is no longer centered on the mother; it is now an infant-focused condition. When comparing cesarean section to vaginal delivery, there is a small increase in risk for the mother but a decrease in risk for the fetus. As parents became increasingly involved in decision making surrounding the pregnancy, the impartiality of the physician’s clinical judgment was muted by the parents’ inherent bias in favor of their child. Parents began expecting perfect babies and healthy moms, and the cesarean section rate rose rapidly to 24.7 percent in 1988. A push for vaginal birth after cesarean (VBAC) began in the mid 1980s and eventually did lead to a decline in cesarean section rates in the 1990s to a new low of 21 percent in 1996.

In 1999 the American College of Obstetricians and Gynecologists released new guidelines requiring the presence of an obstetrician and anesthesiologist, as well as staff capable of performing an emergency cesarean section, for any patient undergoing a trial of labor after previous cesarean section. Many smaller hospitals were unable to meet these in-house requirements, and many physicians cover more than one hospital and are unable to be in the hospital during labor. The immediate impact of these guidelines was apparent. The cesarean delivery rate increased to 29.2 percent by 2004, and the VBAC rate decreased from 28 percent in 1996 to 8 percent in 2004. The cesarean section rate has continued to climb yearly to a high of 32.9 percent in 2009. Finally, in 2010, the rate fell very slightly to 32.8 percent. Only time will tell whether this downward trend will continue. 2010 ACOG guidelines relaxed the earlier requirements for VBAC somewhat, indicating that trial of labor after cesarean(TOLAC) should be undertaken at a facility capable of emergency delivery and stated that most women with prior low transverse incision are candidates for TOLAC.

Prominent causes of the high current cesarean rates include the epidemic of maternal obesity in the United States, excess weight gain in pregnancy, macrosomic infants resulting from increased weight gain during pregnancy, and the increase in gestational diabetes. There is also an increase in twin/triplet/multiple pregnancies and a significant increase in pregnancy rates in women over 40 years of age. Despite a decrease of 3% in total number of births between 2009 and 2010, there was a 2% increase in births in women over 40. Women over 40 have a cesarean section rate 21 percent higher than women in their early 20s. The desire of women to have control over their delivery schedule has led to a rise in the induction rate of labor. Induction is clearly associated with increased cesarean
section rates, particularly in patients with an unfavorable cervix. In a retrospective study done by Zhang, et. al., the cesarean section rate for women who were induced was twice that of women who went into labor spontaneously. Finally, the current legal climate and parental expectations for perfect neonatal outcomes promote quicker decision for cesarean section. There is some thought that maternal demand for elective cesarean section in the United States has had an impact on surgical rates, but a survey by Declor, et. al. in 2006, revealed only 1 of 1,600 patients requested an elective primary cesarean section.

Worldwide, the cesarean rate is increasing. In Asian and South American countries, women have been requesting elective cesarean sections in high numbers for social convenience and from a cultural desire to deliver on certain days. In a sampling done by the World Health Organization, 46 percent of births in certain areas of China were by cesarean, and half of those were patient-requested elective procedures. Vietnam has a 36 percent cesarean rate and Thailand’s is 34 percent. The cesarean rate in Latin America is 35 percent, but certain areas like Paraguay (42 percent) and Ecuador (40 percent) are even higher. Some of the lowest rates worldwide are found in India, 18 percent, and Cambodia, at 15 percent.
Although overall cesarean delivery rates have significant impact on the health care system in the United States as a whole, the practicing clinician must make decisions based on the individual patient, her needs, her desires and her risk factors. It remains to be seen what the future holds for cesarean delivery and how the newest ACOG guidelines will impact the latest statistics.

Kirsten Franklin, M.D., FACOG is a board-certified obstetrician gynecologist. She has been in private practice at Northside Hospital for the past 16 years and is a current member of the Medical Executive Committee.

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Dr. Michael Doherty Discusses Why Doctors Are Choosing Large Multispecialty Groups Over Private Practice

Thursday, March 15th, 2012

by Michael F. Doherty, M.D.
From ATLANTA Medicine, 2011, Career Options in Medicine, Vol. 82, No. 5

Over the past decade, the number of physicians in solo practice, small groups and physician-owned practices has decreased while those working in hospital-owned practices, integrated delivery systems and larger group practices of various types have grown. The shift is driven by two factors — changes in the attitudes and expectations of experienced physicians and newly trained doctors eschewing the traditional model.

Why are experienced physicians leaving private practice? Regulatory and reporting requirements, costly office technology (such as EMR systems, billing and financial software), complex, risk-based compensation mechanisms, rising operating costs, and burnout from running a business in parallel with a clinical practice are the most often cited reasons. In addition, current economics make it challenging for physicians in solo and small group practice to work part time or afford a replacement partner in anticipation of retirement or limiting practice duties. Practice valuations have steadily declined, and selling a practice, if one can find a buyer, does not produce the financial rewards it once did.

In light of these conditions, experienced physicians are seeking employed status as their exit strategy from traditional private practice. Sometimes they are able to sell their practice to a local hospital system. Other times they simply shut their practice down.

The values, goals and demographics of younger physicians make traditional practice options less desirable. They are attracted to predictable hours, flexible work schedules, robust benefits and market compensation linked with professional business management. These elements are more likely to be found in integrated delivery systems, multispecialty groups, and institutional settings than in a small group practice.

New physicians will often have an easier transition to large multispecialty groups than experienced physicians. Experienced clinicians considering a change often wonder what to expect as they move from traditional private practice to a new work environment. How will they know if it will be a good fit for them? One of the biggest questions they have is, “How much control will I have?”

Certainly, the unbridled autonomy of solo practice will not be part of a large group practice. Still, physicians’ opinions will be highly respected and sought after, and a well-run organization will offer opportunities for influence and participation in decisions. Physicians could be involved in interviewing new hires for the staff they will work with, provide input into how night call is organized or negotiate with colleagues on how to best meet clinical responsibilities. They should also expect to be involved in the governance of the organization in a substantive way.

Clinical decision-making will also be different. In solo practice, quality care is“care as the physician sees it.” In larger practices, physicians are accountable to the group’s expectations for quality, service and use of resources.

Large groups usually set specific targets and provide data reflecting how you compare to other physicians with regards to access, screening for preventive services(like mammography) or achieving control of blood pressure. There may be minimum levels for these metrics that you’re expected to meet to remain in good standing in the organization.

Small and solo practices often operate with a physician-centric perspective, while large practices are more centered on patient needs. Established physicians will notice this subtle shift from having a team of people surrounding them to being part of a team surrounding the patient.

Physicians with interests that extend beyond the exam room will find many more opportunities in a large practice. Community involvement, research, clinical management, government relations, marketing, education and recruiting opportunities are often available and most large organizations support these activities through compensated, nonclinical time.

Large practices also provide a variety of prospects for those who want to experience a niche of clinical care that is not feasible given the time and resource restraints of a small practice. These may include areas such as sports medicine, palliative care, elder care, group or home visits and even telemedicine, all of which provide a satisfying complement to day-to-day patient care.

Of course, compensation is also a consideration. In general, compensation and
benefits in a large group setting are likely to be typical for the community. Compensation frequently is based on both individual contribution and the performance of the group. Elements of compensation extend beyond standard productivity measures to include patient satisfaction, utilization of in-house resources (like pharmacy and radiology), and meeting specific clinical outcomes.

Physicians are, by training and nature, resilient individuals, and almost any doctor can adapt to the large practice environment. Those who identify themselves as team players, evidence-based, practical problem solvers, and that see the value of consistent work processes, will find that a large group practice can be a satisfying career option. n

Michael F. Doherty, M.D., is a board-certified oncologist and Chief of Staff for the Southeast Permanente Medical Group, responsible for day-to-day operations management of the critical departments of care delivery for the group.

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Dr. Iqbal Garcha Performs Georgia’s First Single-Incision Robotic Surgery

Wednesday, February 15th, 2012

Dr. Iqbal Garcha recently performed the state’s first-ever Single-Site™ surgery, using the da Vinci® Surgical System. The procedure, a cholecystectomy (gallbladder removal), was performed Feb. 2 by  at Northside Hospital in Atlanta.

In a traditional laparoscopic and robotic surgery, surgeons make several small incisions for the instruments and camera needed to perform the procedure.  However, in Single-Site (single-incision) surgery, surgeons use a single 2-to-2.5-centimeter incision, often at the bellybutton, to reduce the appearance of scarring.  Performing single incision surgery via robotic-assisted technology allows surgeons to provide patients with procedures equivalent to traditional single-incision surgery, but with the advantage of 3D high-definition visualization of the surgical site, and the precision and versatility afforded by robotic instrumentation.

“The da Vinci software automatically detects and re-associates the surgeon’s hands with the instruments’ tips to create an intuitive movement,” said Dr. Garcha.  “And the new flexible design of the instruments allows me to better reach and see the surgical field through the single port, without interference and without causing additional trauma at the port site.”
Single-Site technology allows surgeons to eliminate the multiple incisions, traditionally used for cholecystectomy, by giving them the ability to place all the instruments through a single incision at the bellybutton, without compromising visualization and dexterity.  In addition to providing a superior cosmetic result, surgeons expect this to translate into less pain, a shorter hospital stay and a fast recovery, similar to the multi-incision alternative.

In the Feb. 2 case, the patient went home within three hours after her surgery was complete.  Dr. Garcha performed a second Single-Site robotic cholecystectomy on Feb. 3, with similar success.

Although Single-Site robotic surgery is currently only approved for cholecystectomy, surgeons are actively using robotic technology to perform procedures across a wide range of specialties.  Many of the surgeons on staff at Northside are pioneers in laparoscopic surgery and are nationally and internationally recognized for their expertise in minimally invasive techniques, like robotic surgery and single incision.

Dr. Garcha graduated from the Medical College of Georgia and completed his general surgery residency at Georgia Baptist Hospital in Atlanta. He has been in private practice at Northside Hospital and Saint Joseph Medical Center since 1997. 

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Dr. John McBroom Performs World’s First Robotic HIPEC Treatment for Ovarian Cancer

Wednesday, January 18th, 2012

Dr. John McBroom, gynecological oncologist, recently performed the first Hyperthermic Intraperitoneal Chemoperfusion (HIPEC), a minimally invasive robotic treatment for ovarian cancer, at Northside Hospital. During the procedure, Dr. McBroom used the robot to remove all visible adhesions and cancer within the patient’s abdominal cavity prior to starting HIPEC.  This marks the first time ever that robotic technology has reportedly been used, in conjunction with HIPEC, for the treatment of ovarian cancer.

Growth of ovarian cancer is most often relatively silent and, by the time of diagnosis, it usually has spread throughout the abdominal cavity.  Until recently, treatment options for patients with advanced-stage ovarian cancer have only included surgery and conventional chemotherapy.  However, with HIPEC and robotic surgery, surgeons can potentially improve their odds and reduce the morbidity associated with traditional open procedures.

Performed during surgery, HIPEC delivers heated chemotherapy into the abdominal cavity, which allows a much higher dose of chemo to permeate the diseased tissue than could be accomplished conventionally.  The heat increases the effectiveness of the chemo.  After the surgeon removes as much visible cancer as possible, the heated chemo is circulated throughout the abdomen, for up to 90 minutes, in an effort to kill the remaining cancer cells.

“We are very excited about the possibility of using both technologies to improve outcome and limit morbidity in our patients with advanced ovarian cancer,” said Dr. McBroom.  “Ovarian cancer is typically not conducive to a laparoscopic procedure because the disease can hide and be hard to find. However, the improved dexterity and 3D vision of robotic technology allows us to successfully complete more complicated procedures and, in this case, find more of the disease to remove.”

As a result of Dr. McBroom using robotic technology, in conjunction with HIPEC, his patient was able to be discharged from the hospital two days after surgery and is recovering well.

HIPEC is useful with newly diagnosed patients as well as with patients who have a recurrence with minimal disease. However, whether performed traditionally or with the robot, it is not appropriate for everyone.

Previously, HIPEC has only been performed in conjunction with laparoscopic or traditional open surgery. However, the rise in robotic surgery has given surgeons even better tools to perform the most intricate of minimally invasive procedures and achieve better outcomes for their patients in a growing range of specialties including GYN oncology. Patients benefit from smaller incisions, less pain and scarring, reduced blood loss and need for transfusions, shorter hospital stays, quicker recoveries and reduced risk of infection.

Dr. McBroom is one of an elite group of surgeons qualified to perform the da Vinci Robot’s surgical techniques for gynecologic cancer surgery and is board certified in gynecologic oncology and general obstetrics and gynecology. His honors include AAGL Special Excellence in Endoscopic Procedures Award, Honorary Order of the Spur (3rd ACR, Operation Iraqi Freedom), and the Army Commendation Medal (Operation Iraqi Freedom). He is an active member of the Society of Gynecologic Oncologists, American College of Obstetrics and Gynecologists and American College of Surgeons and American Society of Clinical Oncology, the author of more than 15 published articles and a sought after keynote speaker, nationally and internationally. He is a member of University Gynecologic Oncology, a women’s cancer care center committed to providing patients with state of the art treatment and innovative clinical trial options.

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Nanette Wenger, MD, an Emory Cardiologist, Receives American Heart Association’s Highest Honor

Thursday, December 8th, 2011

Nanette K. WengerThe American Heart Association’s Council on Clinical Cardiology has honored renowned Emory cardiologist Nanette Wenger, MD, with its highest accolade, the James B. Herrick Award, for her profound impact on clinical cardiology practice. Wenger is a professor of medicine in the Division of Cardiology, Emory University School of Medicine, and former chief of cardiology at Grady Memorial, where she has worked to change the lives of patients for more than 50 years.

Wenger received the award at the 2011 American Heart Association Scientific Sessions meeting, where she delivered the Herrick Lecture titled, “Women and Coronary Heart Disease a Century After Herrick: Understudied, Underdiagnosed, and Undertreated.” The award and lecture are named for pioneering physician James B. Herrick, the author of history’s first clinical description of coronary disease.

Wenger has contributed immeasurably to the field of cardiology, particularly heart disease in women. Wenger was among the first physicians to focus on women’s heart disease and to evaluate the different risk factors and features of the condition in women and men. Her pioneering and innovative research in gender differences in cardiovascular disease has influenced both health professionals and the public about these differences in disease development, prevention, diagnosis, treatment and outcomes.

A native of New York City and a graduate of Hunter College and Harvard Medical School, Wenger received her medical and cardiology training at Mount Sinai Hospital before coming to Emory University School of Medicine and Grady Memorial Hospital in 1958. Since then she has been a trailblazer in the field of cardiology as author and co-author of more than 1,400 scientific and review articles and book chapters.

Wenger co-authored the 1993 landmark publication in the New England Journal of Medicine that called attention to the fact that heart disease in women was ubiquitous, often overlooked, and usually inadequately managed. The article aggressively addressed the prejudice that heart disease was solely a man’s disease.

Wenger remains one of the most outspoken and best-known champions for women with cardiac disorders. Thanks to her clinical impact we know that cardiovascular disease is the number one killer of women in the United States, accounting for 38 percent of all female deaths– more than all forms of cancer combined.

Wenger helped write the American Heart Association’s 2007 Guidelines for Preventing Cardiovascular Disease in Women and the recent 2011 update, Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women. She is a past vice-president of the American Heart Association, past governor for Georgia of the American College of Cardiology and a past-president of the Georgia Heart Association.

Wenger has served as a member and frequently chairperson of over 500 committees, scientific advisory boards, task forces, and councils of the American Medical Association, the American College of Cardiology, the American Heart Association, the National Heart, Lung, and Blood Institute, and the Society of Geriatric Cardiology. In 2010, the Georgia Commission on Women honored Wenger with its prestigious Georgia Woman of the Year Award.

Most recently, Wenger has focused her efforts on raising the consciousness of the U.S. and international cardiology communities concerning heart disease in the elderly.

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