M.D. Update Issue #84

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #84

SPECIAL SECTION

Cardiology/Pulmonology

Dr. Susan Smyth leads UK Gill Heart Institute in constant physician-science interaction to power research and innovation

VOLUME 5, NUMBER 2

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LETTER FROM THE PUBLISHER

Volume 5, Number 2 ISSUE #84

Gil & Liz Prepped for the OR

All the Best, Gil Dunn Publisher, M.D. Update

Send your letters to the editor to: jnewton@md-update.com, jennewton01@gmail.com, or (502) 541-2666 mobile Gil Dunn, Publisher: gdunn@md-update.com or (859) 309-0720 phone and fax 2 M.D. UPDATE

Z NEWELL

I

t’s not every day that a nonmedical person like myself is allowed to witness life-changing heart surgery, so when the opportunity is available, we leap at it to better understand and present the stories we share with the readers of M.D. Update.

Such was the case on January 23rd when M.D. Update photographer Liz Haeberlin and I observed and she photographed the brilliantly orchestrated and choreographed TAVR surgery at Saint Joseph Hospital in Lexington.

Observing the OR staff and physicians prepare for surgery reminded me of backstage at a performance, a place I know a little something about. The props are in place, the quiet murmurs, the expectation and anticipation, the eye & hand gestures that communicate silently between the players and the backstage staff. Then it’s “Lights, Camera, Action… let the performance begin.”

I know that surgical procedures similar to this occur countless times, every day in numerous OR’s around Kentucky and around the world. For the OR staff, maybe “it’s business as usual.” For the layperson, I assure you, it’s anything but the usual.

We greatly appreciate all of the access the medical professionals give us to tell the stories of their work. We spoke with Dr. Susan Smyth, director and chief of Cardiovascular Medicine and several of the physician-researchers at the UK Gill Heart Institute; Dr. Jesse Roman, chair of the Department of Medicine at the University of Louisville; Dr. Rebecca Shadowen, director of Infection Control and Hospital Epidemiologist at Greenview Regional Hospital in Bowling Green and more.

All that plus Legal, Financial, Relationship Counseling, News, Arts and Events are waiting for you inside. Please check the Editorial Calendar for your specialty and contact us if you have a story to tell.

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Jan Anderson Nezar Falluji, MD Dermot Halpin, MD Donald P. Moloney Scott Neal Rebecca Shadowen, MD Douglas Stephan Mac Stone

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CONTENTS

ISSUE #84

COVER STORY 4 HEADLINES

100,000 TIMES A DAY

5 FINANCE 6 LEGAL 9 ORGANIC FARMING 10 PHYSICIAN VIEWPOINT 12 COVER STORY 17 SPECIAL SECTION: CARDIOLOGY/PULMONOLOGY

24 COMPLEMENTARY CARE 26 NEWS 31 EVENTS

Constant physician-scientist interaction powers UK Gill Heart Institute and the innovative care it brings Kentucky’s cardiac patients

32 ARTS

BY TIM CORKRAN PAGE 12

SPECIAL SECTION  CARDIOLOGY/PULMONOLOGY

17 17 RAISING THE GRADE: UOFL PULMONOLOGY PROGRAMS

19 19 FOUR-PART HARMONY: KENTUCKYONE HEALTH HEART TEAM 

23 23 MINIMALLY INVASIVE HYBRID CORONARY REVASCULARIZATION: SAINT JOSEPH HOSPITAL  ISSUE#84 3

HEADLINES

Health Care Issues for the 2014 Legislative Session Part 2 Since my first hot topic began with Smoke Free Kentucky in January, I believe I will begin where I left off. HB173 passed the House Health and Welfare Committee on Thursday February 6th and is awaiting floor vote mid-February. This is the fourth year the bill has been filed but it appears we have finally reached a tipping point as a result of the whirlwind of effort by many individuals and groups such as the KMA, the Kentucky State Chamber of Commerce, Kentucky Health Departments and Health Boards, all medical specialists that deal with the aftermath of secondhand smoke, Kentucky Youth Advocates, Prevent Child Abuse Kentucky, Cooperative Extension Agents in Kentucky, and far too many to list in a limited space.

We still have far to go. Senator Julie Denton filed a companion bill to HB173 in the Senate, however the President of the Senate is opposed to the bill and sent it to the Judiciary Committee with the hope it will not be voted out of the committee. This is where the outrage of supporters would be very beneficial! I hope you can help by calling all members of the Senate Leadership.

FYI … I was invited to the White House press conference by our U.S. Surgeon General Lushniak, Dr. Tom Fielden, Director of the CDC, and Secretary Kathleen Sebelius to celebrate the 50 Years of Progress since tobacco was identified to cause cancer. What an incredible experience for me!

Other bills of interest include HB 98, a bill allowing students self-treatment of diabetes symptoms in school settings or treatment by a trained staff person, who has completed a training program by the American Diabetes Association. It did pass the House after two years of debate and is now referred to the Senate Health and Welfare Committee.

You may be aware of HB157, a bill filed

by Rep. Addia Wuchner and myself for the second time, which was requested by the Child Death Review Panel. This bill provides 60 minutes of continuing education on the recognition and prevention of pediatric abuse head trauma for pediatricians, radiologists, family practitioners, emer4 M.D. UPDATE

gency medicine and urgent care physicians.

At the same time, it sunsets the mandatory HIV training since that topic is now covered in medical schools. HB 157 passed the House

BY Susan Westrom and has been sent to the Senate Licensing and Occupations Committee.

Several bills have been filed for the protection of vulnerable adults, which include an adult abuse registry as well as the requirement of a National and State Background Check Program for prospective employees of long-term care facilities.

The KMA lobbying team and ARNP’s worked diligently over the summer to come to an agreement on physician collaborative agreements. SB 7 filed by Senator Hornback glided through the Senate early in the session, passed the House easily, and was signed by the Governor on February 6, 2014. You may recall that this is an issue that was debated at least four years. Great job docs and lobbyists!!

Physician Assistants were represented in SB 41 sponsored by Senator Tom Buford.

This bill requires a supervising physician to review and countersign at least 10 percent of the medical notes written by the PA every 30 days. This bill passed the Senate and is now in the House Health and Welfare Committee.

SB119 was filed to establish a Medical Review Panel system for use in civil litigation relating to nursing homes and health care providers. It has been sent to the Senate Health and Welfare Committee.

Last year the same bill came to the House Health and Welfare Committee but was not heard. If this bill is to be taken seriously, it should be sent to the Judiciary Committee for full vetting.

Several medical cannabis bills have been filed to legalize medical marijuana. SB43 and HB 350 have been filed to permit the dispensing and use of pharmaceutical-

grade cannabadiol oil for the treatment of certain debilitating conditions. Parents of children who have autism or who seizure hundreds of times day, as well as patients with Glaucoma, Epilepsy, and Muscular Dystrophy have been visiting legislators to share their stories. Now that the issue is here, I do not expect it to go away. I hope the medical community will learn along with us in Frankfort in order to assist in guiding the conversation.

This is a new one for me. Senator Tom Buford introduced a bill to license Acupuncturists. SB 29 has passed the Senate and was sent to the Licensing and Occupations committee. Another interesting bill was filed by Senator Julie Denton.

SB52 would allow health professionals to charge $25.00 to Medicaid patients for missed appointments.

We did hear great news about a settlement from two pharmaceutical companies for $32 million. Attorney General Jack Conway and Governor Beshear have agreed this windfall should be dedicated for drug treatment in Kentucky. Kentucky has one of the worst prescription drug problems in the country and heroin has become a drug of choice since HB1 created tougher laws and enforcement against pill mills. This money is critical to provide care in drug abuse treatment programs.

During a regular 60-day session, on average 1,300 bills are filed, but very, very few pass. Our committees meet once a week, and the number of bills heard in two hours is very limited. We cannot file any new bills after the end February, so it is easy to see why the legislative process can be so slow. I always say that if you pass a bill the first year, it is a miracle, since the vast majority take two to three.

Susan Westrom (D) was elected as State Representative of the 79th district in Lexington, KY in November 1998. Westrom sits on the House Standing Committee on Health & Welfare as well as Agriculture; Appropriations & Revenue; BR Sub-committee on Economic Development & Tourism; Natural Resources & Environmental Protection; Horse Farming (co-chair); Licensing and Occupations (Vice Chair). ◆

FINANCE

Saving Too Much?

During his annual review with us, one of our clients half-jokingly remarked that he felt that he and his wife were “saving their way into poverty.” He is employed by a not-for-profit hospital and is therefore eligible to contribute to a 403(b), a 457, and a health savings account. Last year, like most good-savers, he maxed-out his contributions to all three plans. As you probably already know, the contributions all came from current income. He recalled, from an earlier session with me that he has five choices, and only five choices, with each dollar of income that comes his way each year: pay taxes, pay on debt, save some, spend some, give some, and it’s all gone.

Obviously, to the extent that a dollar gets saved, the same dollar cannot be spent, and vice-versa. As the spending slice of the pie gets cut in order to save, it may eventually feel like an impoverished living standard.

This begs the question: is it possible to save too much? The short answer is yes.

Millions of Americans are saving too little, but the opposite is also true: millions of us may be saving too much. The trick is properly figuring out in which camp we have pitched our tent while there is time to move it if we need to. The answer depends in part on the kind of financial planning that we have undertaken. You see, deciding how much to save is incredibly complex. Dr. Laurence Kotlikoff of Boston University claims that almost everyone is getting it wrong!

Some websites and even a few experienced financial planners would have us believe that developing a financial plan can be boiled down to a few inputs and some simple time value calculations. In fact, the calculators on three of the nation’s leading mutual fund providers’ websites use five or fewer questions to recommend how much you should save or the amount of insurance you should buy. This is tantamount to a 15-second history and physical for a new patient. We’re afraid that too many companies recommend high-yield, high-risk, and high-cost investments because it’s in their best interest and not that of their client.

Popular rules of thumb are often used that indicate 75-85 percent income replacement rates are appropriate along with a 4

percent spending rate. Thorough economic studies suggest that this may be much too simplistic to be valid. There are far more variables to consider when casting a valid financial plan.

BY Scott Neal So what’s the danger in following the recommendations of the computer-generated financial plan?

For starters, you can squander your youth rather than your money. You can spend far too little when you’re young, sacrificing living standard, and die at 66. You can buy too much life insurance and outlive it. Or, in search of higher returns, you can be cajoled to invest in risky assets and lose your shirt.

Kotlikoff and his colleagues at BU suggest that there’s a better way. They build upon the 1930 work of Yale’s Irving Fisher and the lifecycle model of MIT’s Franco Modigliani.

It’s called consumption smoothing and is the economics’ approach to financial planning.

With skilled minds, modern computer technology, and dynamic programming, the chicken and egg problems usually associated with financial planning can be solved. Most planning calculators began by asking the user to specify how much they would like to have to spend in retirement. For most of us this is nothing more than a pure guess.

Starting with good economic theory, leads us to the right target.

Setting your own targets probably results in “consumption disruption,” says Kotlikoff. Target to spend too little and you will under-save and under-insure; target to spend too much in retirement and you will over-save and over-insure. Even very small targeting mistakes can lead to major disruptions in present day living standard.

Think for a minute about why the income replacement rate methodology might be flawed. It assumes that there is some high degree of correlation between pre- and post-retirement spending. It totally ignores demographics. It usually assumes no spend down of wealth. It further assumes

that the current savings rate is optimal and fixed or simply adjusted for inflation. And it confuses spending with living standard.

So what kinds of questions can the economics approach begin to answer? Properly understood, economics can smooth and protect your consumption, raise your living standard, and price your passions. It can inform your choice of a career or particular job. It can help you decide to invest in more education, or not. It can help you choose, accelerate, or refinance a mortgage.

It can help you decide what types of retirement accounts are appropriate for you and the amount of annual contributions that you need to make to the plan. It can help you calculate and time your retirement account withdrawals. It can address when to take Social Security and can certainly give assurance that you have chosen the right date to retire. It can provide the economics of deciding whether to have another child, the benefit of getting married, or divorced for that matter. It can price the decision to buy an airplane (or some other expensive mode of transportation), as well as whether to move to a sunnier climate.

Certainly this is what financial planning has promised for so long. However, simplistic answers to such complex questions are not the answer. Just as new medical technology can enhance your ability to practice medicine, new financial research and technologies bring us as financial planners into the 21st century. I’m old enough to remember when the computing power to do sophisticated modeling could only be housed in a mainframe and extracted by punching cards, but I’m not so old that I can’t keep up with the times. Thanks to Dr. Kotlikoff and his colleagues, 21st century technology is accessible. It is our belief that good theory practiced with good technology yields better outcomes.

Scott Neal, CPA, CFP, is president of D. Scott Neal, Inc., a fee-only financial planning and registered investment advisory firm that subscribes to the fiduciary oath. Offices are located in Louisville and Lexington. He can be reached by calling 800-344-9098 or via email: scott@dsneal.com ◆ ISSUE#84 5

LEGAL

Mediation for Resolving Disputes in the Healthcare Setting People will always disagree, and unfortunately the health care field is no exception. Issues or claims could arise for Kentucky physicians and healthcare administrators over a contract, lease, medical equipment purchase, employment, professional non-compete agreement, an office premises slip and fall injury, or a patient complaint/claim. With the evolving implementation of the Affordable Care Act, disputes are likely to arise in the Accountable Care Organization (ACO) setting among ACO team members, or due to ACO board and owners facing new quality compliance and outcome standards, raising peer review issues and possible confidentiality concerns.

Any of these disputes could result in significant litigation expense, substantial time investment, and emotional stress. Alternative dispute resolution (ADR), and mediation in particular, is a means to manage conflict to produce a more satisfactory outcome. Mediation is the intervention into a disagreement by an impartial third party who can help the contending parties reach their own mutually acceptable settlement of the issues in dispute.

What are the benefits of mediation?

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS

include enforceable ADR provisions. The opportunity for ADR can be waived by a party under certain circumstances if not timely invoked, so it is important to determine if ADR is required or available as soon as a dispute arises.

If a party refuses to participate in ADR, the other party may be able to enforce the ADR provision under the Kentucky Uniform Arbitration Act1

BY Donald P. Moloney, II

BY E. Douglas Stephan or the Federal Arbitration Act2. There may also be defenses to the enforceBased on many years of experience, ability of an ADR agreement, especially both as advocate and mediator, mediation between a long-term care provider and their generally: resident.3 • Is less expensive than litigation; • Gets resolved more quickly than litigation; If there is no ADR agreement, • Gives the parties more control of the outcome; how do you get to mediation?

• Often addresses issues that cannot be Mediation is voluntary unless there is an resolved in a judicial forum; and ADR agreement, or you are already involved • Helps to preserve a professional relationship. in litigation and the court has ordered you

to mediate. If the timing is right, contact the What do you do when a other party and explain your desire to medidispute arises? ate the dispute. Once the parties agree to When a conflict arises, first determine mediate, the mediator must be selected either whether mediation or some other form of ADR pursuant to the terms of the ADR provision may be an option under a contract or appli- or by mutual agreement. The mediator will cable law. Many healthcare-related contracts coordinate logistical details, then circulate

AND HEALTHCARE PROFESSIONALS

CALL FOR PARTICIPATION 2014 Editorial Opportunities * Issue #85 - March Gastroenterology, General Surgery, Bariatrics, Surgery Centers / Nutrition

Issue #88 - June/July Dermatology, Plastic Surgery, Hand & Foot Surgery / Men’s Health

Issue #91 - November Neurology, Pain & Addiction / Mental Health

Issue #86 - April Public Health & Rural Health, Endocrinology / Physician Extenders Issue #87 - May Women’s Health, Pediatrics / Dental Health

Issue #89 - August/September Orthopedics, Physical Medicine, Rheumatology / Acupuncture Issue #90 - October Oncology, Radiology, Imaging / Hospice, Home Health

Issue #92 - December/January 2015 Nephrology, Urology, Pathology / Organ Donation SEND PRESS RELEASES TO: news@md-update.com

TO PARTICIPATE, PLEASE CONTACT:Gil Dunn, Publisher / gdunn@md-update.com / (859) 309-0720 Jennifer S. Newton, Editor-in-Chief / jnewton@md-update.com / (502) 541-2666 *EDITORIAL TOPICS ARE SUBJECT TO CHANGE. 6 M.D. UPDATE

a mediation agreement regarding the terms upon which mediation will be conducted.

The mediator may also request a pre-mediation position statement from each party.

What happens at the mediation and what is your responsibility?

You or a member of your staff may act as the negotiator unless you have retained legal counsel. Keeping in mind that the mediator’s job is not to decide the outcome of the mediation but to facilitate an agreement between the parties, it is important for a successful mediation to have all of the decision makers physically present at the mediation.

The mediator will convene the mediation, introduce the parties, and go over ground rules and procedures, including: The mediation is confidential. If unsuccessful, the mediator cannot be subpoenaed as a witness in any legal proceeding regarding what the parties discussed at mediation; Each party will have a turn to present their case. While the other party may hear information they do not agree with, they

are not to interrupt the person making the presentation; A good mediator will state goals, mutual expectations and possible outcomes for the negotiations, clarify the parties’ interests and positions, and identify specific issues in a non-judgmental manner. The mediator may remind all participants to listen, use a positive tone, bargain in good faith, and be willing to compromise to achieve a resolution; After the parties state their positions, the mediator typically has them move to separate rooms to caucus with the mediator privately to narrow the issues. The mediator will ask open-ended questions, encourage participants to tell their story, and identify weaknesses in their position they may have minimized, overlooked, or ignored.

The mediator will then begin negotiation through a process of communicating offers and counter-offers. A skilled mediator develops the parties’ awareness of the costs and benefits of resolution and the possible settlement options.

If a resolution is reached, the terms must be reduced to writing in a “mediation agree-

Why do some mediations fail?

Reasons a mediation will end with an impasse include: • The parties’ were not prepared to mediate; • Parties make inconsistent or conflicting offers; • A party refuses to further compromise; • Third parties were not invited to participate; or • The person with ultimate settlement authority fails to attend.

Considering these factors before a mediation begins will result in a far greater likelihood of the mediation being successful.

Donald P. Moloney, II, and E. Douglas Stephan are partners with Sturgill, Turner, Barker & Moloney, PLLC. Moloney and Stephan concentrate their practices in the area of healthcare and medical malpractice defense. Moloney is a certified mediator with the Sturgill Turner Mediation Center. They can be reached at patmoloney@sturgillturner.com, dstephan@sturgillturner.com or (859) 255-8581. ◆

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ISSUE#84 7

8 M.D. UPDATE

ORGANIC FARMING

Milk as Medicine?

Let’s start with the premise that what we eat grass and forage matters to how our human body functions. meals to livestock Let’s also recognize that the conversion from from pasture in a food taken in to resulting human health manner that benis wildly complex. It seems to be widely efits the pasture accepted by the medical community that we itself by allowing should balance the various types of fats availa quick regrowth able to us in our diets. Bring your own view for another on the animal versus plant-based protein meal after sevtheories to the conversation. Organic farmeral weeks. The ers provide us an opportunity to consume legumes in the

BY Mac Stone wholesome, healthy fats in our diet. And, pasture pull nitrothere is now evidence showing that how gen from the air in a symbiotic relationship your food is managed on the farm makes a with a rhizobia bacterium. In a condifference for your nutritional health. ventional commercial system, grain crops An 18-month, national study concluded grown with chemically produced nitrogen that dairy cows who consumed a forage- fertilizers are fed to the livestock. Unless based grass/legume diet produced milk with you are purchasing your milk and other 25 percent less omega-6 fatty acids and 62 dairy products directly from the farmer, the percent more omega-3 fatty acids, com- process-verified Certified Organic milk is pared to cows who consumed a higher the only way to know you are getting the percentage of grains and less forage in their good stuff. When you see the organic seal, diet (Benbrook et al., PLoS One, 2013). that product has been carefully managed to The Certified Organic milk tested in the maintain integrity throughout the processstudy had an omega-6: omega-3 ratio of ing and distribution system.

2.28, while the conventional commercially  There are other sources of beneficial produced milk averaged a ratio of 5.77. It omega-3 fats, but really, you can only eat is generally accepted that diets with lower ratios pro- WHEN YOU SEE THE ORGANIC vide us the right balance of SEAL, THAT PRODUCT HAS fatty acids instead of making our bodies figure out BEEN CAREFULLY MANAGED what to do with the wrong kind of fats. All individual TO MAINTAIN INTEGRITY omega-3 fatty acids were THROUGHOUT THE PROCESSING AND higher in the organic milk.

With encouraging ratios DISTRIBUTION SYSTEM. like these, there is no reason to avoid or limit the servings of grass-forage-based dairy prod- so many walnuts, and fish is not so popular ucts, especially since they are so tasty and for breakfast. Between milk and cheese and fun to eat. yogurt and butter, every meal has a place Certified Organic farms document and for dairy. Many local artisan cheeses are have-third party verification that they oper- made from pasture-based products; just ate a grass-forage-based system. These sys- check with the producer to verify the feedtems optimize natural resources and require ing program used. With similar ruminant much less steel, diesel fuel, and pesticides digestive systems, it stands to reason that than conventionally produced food prod- beef and lamb would have a similar response ucts. No genetically modified organisms to grass-based versus grain-based feeding (GMOs) are allowed in organic farming programs, and the data is being collected systems, period. Using simple electric fence (Eatwild.com). Look for Certified Organic technology, farmers can effectively provide beef along with dairy, as it also is verified

to be grass-based or totally grass-fed. The beauty of the milk study is the consistency of the sample collection and similarity within feeding systems.

All you vegetarians and vegans feeling like you don’t have to worry about any of this? Think again. In a study published in the Journal Food Chemistry, Bohn et al., 2013, determined that certified organic soybeans contain less omega-6 fatty acids, more total protein, more sugars, and less fiber than conventional systems and/or genetically modified soybean farming systems.

From the 35 different variables tracked in this study, among them nutrient profiles and pesticide residues, scientists can accurately identify which of the three production systems was used to produce the beans in blind testing of their model. The vast majority of soybeans grown in this country are patented genetically modified plant varieties, as is corn grain for livestock, and increasingly vegetables. In a fruit fly study, the flies lived longer and had more offspring when consuming organic soybeans and/ or organic vegetables than when consuming conventionally farmed equivalent diets (Chhabra et al., PLoS One, 2013).

So it seems conventional thought is telling us to avoid or limit our intake of dairy and other animal products because of the fat content. When those products come from conventionally farmed feeding systems, that assumption is correct.

When meat and dairy products are produced in organic grass-forage-based systems that are closely aligned with the natural ruminant digestive tract, the resulting nutritional quality is right in line with our own dietary needs. Therefore it stands to reason, if you eat organic from the “Farm-U-see,” you can avoid a need for a pharmacy. As far as I’m concerned, that makes milk my medicine.

Mac Stone, BS Agronomy UK, MS Animal Science UK; Former Executive Director, Office of Marketing, KY Dept. of Agriculture; Chair, National Organic Standards Board, Board Member 2011-2015; VP, Lexington Farmers Market; Currently, Director for Sustainability of Farms and Families, KSU; Owner/operator of 375-acre Certified Organic Farm in Scott Co., KY. ◆ ISSUE#84 9

PHYSICIAN VIEWPOINT

Travel Medicine

Vaccines, Prophylaxis, and Self-Treatment “The world is a book and those who do not travel read only one page,” said St Augustine. There are so many held in captivity in our world – some by culture, some by tyranny, some by poverty, and some by limitations of their own choices. With observation and experience of the world around us comes great understanding. The growth we acquire by eyewitness of another culture, person, and geography broadens our abilities. As we move to new and different experiences and contacts, we write more pages in our book, deepen empathy, perspective, and tolerance. Where would we be if travelers such as Christopher Columbus and Amerigo Vespucci had never set sail?

These are some of the reasons I choose to provide Travel Medicine services.

The patient who seeks pre-travel screening should be clear on their itinerary and purpose of travel. It is important for the provider to be up-to-date on outbreaks and any worldwide epidemics, restrictions, or military uprisings. Prophylaxis and vaccinations are specific to the area of travel and activities. For example, those traveling to an endemic area for Japanese Encephalitis Virus need the costly and multiple injection vaccine series if they would be staying >1 month and/or with significant exposure to pigs and livestock. Travelers to areas with

any concerns with the travel medicine specialist.

This will assist in avoiding medical complications, drug interactions, and behaviors that may have risk associated.

There are

BY Rebecca D. Shadowen, MD, FSHEA three areas all travelers will need addressed. One is vaccinations. All vaccines need to be updated (TDAP, Pneumovax, Influenza, and one adult Polio vaccine). Special considerations are necessary if the traveler has not received all the vaccine primary series as a child.

If the traveler is going to an area with Meningiococus or Yellow Fever, these vaccines should be administered. Most will need Typhoid (I prefer the oral live attenuated vaccine for better efficacy and longer duration of immunity) and Hepatitis A series. Hepatitis B is only recommended if potential blood or sexual exposure is anticipated. Other occasional vaccines are tied to the traveler’s specific risk exposures.

The second area to address is prophylaxis, where the major issue is Malaria. The prescriber must discern resistance to anti-

THE PRACTICE OF TRAVEL MEDICINE IS COMPLICATED, MUST BE INDIVIDUALIZED, AND REQUIRES ACTIVE EFFORT TO BE AWARE OF EMERGING INFORMATION WORLDWIDE. outbreaks in infectious diseases, such as H5N1/H7N9 Avian Influenza, Ebola virus, Dengue or SARS, need to be counseled on the risk, protection, and avoidance. Rarely, travel should be postponed or reconsidered.

In addition to this, a patient must share all their health problems and information, including if they could be pregnant, have immunodeficiency, take medications, and 10 M.D. UPDATE

malarial therapy in the region(s) of travel, the patient’s ability to comply with any one regimen, medical co-morbidities, age, drug interactions, and cost. For example, an individual with even mild arrhythmias should take caution in using Mefloquine.

It would not be wise to dose a medication once a week if the patient cannot keep up with that dosing regimen. No regimen is

useful if the patient cannot afford the medication. In some cases, episodic treatment, where minimal exposure is anticipated and the traveler can comply with insect repellent use, is appropriate. There is more that can be transmitted transdermally than just Malaria and Yellow Fever. Therefore, clear instructions on insect repellent use and mosquito netting for sleep is necessary where indicated. Further considerations, such as altitude sickness for selected patients traveling to high elevations are individualized.

The third consideration is self-treatment for illnesses that may frequently develop during travel. Most patients are taking a relatively short trip spanning a week or two.

If a simple infection of the lungs, urine, or skin develops, a significant amount of travel days could be spent seeking healthcare in a foreign country. Sending travelers with options to self-treat a mild infection is very reasonable. Additionally, information about traveler’s diarrhea, toxic megacolon, how to self-treat with/without PeptoBismol and/or antibiotics should be given in written format to be available at the time of need. It is difficult to remember the great amount of information given to a traveler in this setting, making simple written instructions very helpful. Sleep agents, anti-histamines, anti-diarrheal agents, and motion sickness medications are examples of other self-treatment options to consider.

The practice of Travel Medicine is complicated, must be individualized, and requires active effort to be aware of emerging information worldwide.

Why See a Travel Medicine Specialist?

When the traveler is seen by a skilled Travel Medicine specialist for pre-travel evaluation, there are very few issues that develop upon their return. Although many do not understand why they should see a specialist before traveling, after their visit the benefits become very clear. Travelers to my office watch a five-minute video revealing the many infectious diseases they

can be exposed to throughout the world.

Meeting with the physician for further specific counseling and screening allows questions and concerns to be addressed. As a Yellow Fever Vaccine Center, my office is able to move travelers quickly through their needed vaccinations and have prophylaxis and self-treatment medications sent to their pharmacy of choice. Once established, there is ease and accessibility for any posttravel problems.

I am fortunate to have established my practice in Bowling Green, Kentucky. As an honor graduate of Western Kentucky University, I always held the area as an ideal prospect for residence. My husband and I met at WKU and trained in medicine together. As the time approached to choose a job, we realized that this region was totally underserved for our specialties – endocrinology and infectious diseases. Recently,

Bowling Green has been listed as one of the top places ideal for retirement. After 25 years here, that is an added bonus.

Over the past 25 years in south central Kentucky, the need for a Travel Medicine specialist has not waned. In the past five years, I have seen many more travelers, approximating a four-fold increase.

Certainly, the economy has become global, the people integrated, and the world our pages to turn.

Rebecca D. Shadowen, MD, FSHEA, is with Medical Specialists of Central Kentucky and is the director of Infection Control and the Hospital Epidemiologist at the Medical Center and Greenview Regional Hosptial in Bowling Green, Kentucky. She is board certified in internal medicine and infectious diseases and specializes in infectious diseases, healthcare epidemiology, and travel medicine. ◆

Sturgill Turner’s health care legal team is committed to providing comprehensive legal services to health care professionals, institutions and managed care organizations.

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THIS IS AN ADVERTISEMENT ISSUE#84 11

100,000 TIMES A DAY

Eric Endean, MD, is a vascular surgeon pioneering the use of grafts to repair aneurysms.

PHOTOS COURTESY UK HEALTHCARE

12 M.D. UPDATE

UK HEALTHCARE

Constant physician-scientist interaction powers UK Gill Heart Institute and the innovative care it brings Kentucky’s cardiac patients

COVER STORY

BY TIM CORKRAN PHOTOGRAPHY BY JOHN LYNNER PETERS0N AND GIL DUNN

Translational Science on the Ground

Translational science requires doctors, researchers, and staff to work together to produce the “bench-to-bedside” successes that are being experienced at the Gill.

“Those of us at the Gill feel very passionately that we want to make a difference, not just to our individual patients, but more broadly to cardiovascular care,” says Smyth. The process of moving research discoveries to health care solutions gains dynamism and speed when it happens beneath one roof. Although the enthusiasm and pride such successes have engendered at the Gill is palpable, faculty and staff are resolute in their belief that there are always areas open to inno-

vate and improve and to impact health care beyond the state’s borders. Smyth can cite many areas where “we are having a national impact and changing cardiovascular care – not just in Kentucky, but across the country.” Five of them are profiled below.

Cardiac MRI: Unlocking the Power of Imaging

JOHN LYNNER PETERSON

With heart disease the #1 killer in the US and KY ranking second nationally in mortality because of it, it’s imperative that the Commonwealth possess a comprehensive facility to address cardiac issues. The collaborative culture at the UK Gill Heart Institute all but ensures it will fill – and exceed – that critical role. UK’s commitment to translational science – the process of turning a basic science discovery into applications for human patients – provides context for all the work performed there.

Since its inception in 1997, the Gill has had a commitment to providing excellence in cardiac care, education of the population, and outreach to other medical facilities.

In that time it has made its mark on the state. Its fourth commitment, to research and innovation, however, forms the context for the others. “Research and innovation are the platform that drives everything we do. It enlightens our approach to patients, to education, to outreach,” says Director and Chief of Cardiovascular Medicine Susan S. Smyth, MD, PhD. How this research and innovation takes place is just as integral to Gill’s success: collaboration between physicians and scientists are at its heart, producing the lifeblood of the Institute.

Director of Cardiac Imaging Vincent Sorrell, MD, is the kind of person in whose hands you want very powerful tools. As he expands the limits of the Gill’s cardiac imaging program, Sorrell energetically pursues higher resolution with less radiation to patients, and convinces others that his machines can save money on patient care downstream. With the Gill’s translational imaging program team, including Steve Leung, MD, Brandon Fornwalt, MD, PhD, and Moriel Vandesberger, PhD, Sorrell is making sure the latest equipment is used to its maximum potential. He says, “It takes a team of radiologists and cardiologists to do cardiovascular imaging the right way. We Susan Smyth, MD, PhD, work in a very tightknit group.” director and chief of Nuclear stress tests and ultrasound Cardiovascular Medicine, says are the traditional tools for cardiac “Research and innovation imaging, but state-of-the art MRI scanare the platform that drives ners and CT scanners, which require everything we do.” special utilization to produce good heart data, are increasingly employed at the Gill. “Just because you have an MRI scanner doesn’t mean you can see the heart.

You have to invest a lot of effort and resources and money to see this thing that beats 100,000 times a day,” says Sorrell.

For Sorrell and his clinical team, their main preoccupation is determining the “best first test” for each patient so that down the line, fewer tests are needed. Sorrell relies on physicians like Fornwalt and Leung, who create new imaging tools and even advise the scanner’s imaging programISSUE#84 13

COVER STORY Vincent Sorrell, MD, director of Cardiac Imaging, expands the limits of imaging by pursuing higher resolution with less radiation to patients.

mers on how their software can better serve clinicians and produce new testing options.

Vandesberger is the go-to-guy for providing heart imaging all the way down to the cellular level.

Grafting Aneurysms: From Mice to Mankind

Vascular surgeons David Minion, MD, and Eric Endean, MD, are pioneering the use of grafts to repair aneurysms. Their work relies directly on the groundbreaking research conducted by the Gill’s Alan Daugherty, PhD, DSC. Daugherty has created a model of aneurysm development in mice and is demonstrating how to prevent aneurysms from growing or rupturing through grafting.

Endean says Daugherty’s work has advanced his and Minion’s abilities to treat complex aneurysms with an endoscopic approach, “pushing beyond what grafts are typically supposed to do by using components of the grafts to treat more com-

plex disease processes.” The endoscopic approach is key for patients with multiple co-morbidities for whom major surgery is highly risky.

Recently they treated a former Cleveland Clinic patient whose severe aneurysm was deemed to be unrepairable. The team successfully modified the grafting process and was able to stop the aneurysm from rupturing. Endean notes that Minion is getting more of these kinds of referrals, “patients who have been treated at other institutions and have no other options are being sent to him to see if something can be done.” Such successes are integral to effectively treating modernday cardiac patients, as they increasingly have multiple health problems, many of which are due to the very high incidence of smoking, obesity, and diabetes in Kentucky.

Endean acknowledges that his work with Minion, in pushing boundaries of aneurysm repair, has been made possible by the Gill’s openness to innovation: “The uniqueness of UK is that we have the spectrum. We have people who are at the forefront of [examining] aneurysm development and repair, and we have surgeons who can have cross-talk with them.

Surgeons can go back to the scientists and say, ‘These are the things we struggling with.’” You could call that the “bench-tobedside-to-bench” approach.

Steve Leung, MD, is part of the translational imaging team that creates new imaging tools and advises programmers how their software can better serve clinicians.

14 M.D. UPDATE

Antiplatelets: Then and Now

Smyth started out planning to be a hematologist. Her interest in platelets was piqued by the first big aspirin study in the 1980s, which demonstrated that platelets played a role in heart disease and pushed her towards cardiology. “I realized that if I wanted to target platelets and make a difference, the place to do so was in cardiology.” Her studies have revealed how integral platelets are to a series of body processes, from the lymphatic system, arthritis, and migraines to pneumonia and sepsis.

Her work on antiplatelet agents at UK has allowed her lab to serve as a core lab for some of these large trials to look at some of the basic changes in platelet function. Their findings are then applied back to the large (20,000 patient) trial.

One area she is currently investigating is how platelets may exacerbate pneumonia.

By examining the Kentucky Medicaid database, she and fellow researchers found data to suggest that patients who presented with pneumonia while taking antiplatelet medications may do better than pneumonia sufferers who were not on any antiplatelet drugs, which was sufficient to launch a study. Her group at UK has now begun an investigative trial to determine if one of the new antiplatelet drugs may actually improve outcomes.

Stem Cells to the Rescue

The value of UK’s culture of translational science and the Gill’s culture of multidisciplinary collaboration are also exemplified in the experience of Michael Sekela, MD. Sekela is a heart surgeon who recently migrated to regenerative medicine and stem-cell experimentation. Along with Ahmed Abdel-Latif, MD, PhD, an interventional cardiologist who delivers stem cells to patients in the catheterization laboratories and studies the role of stem cells in heart repair, he is embarking upon an experiment with the potential to reverse the decline of failing hearts and that may bring hope to cardiac patients who have exhausted all their options.

Sekela recently returned to the University (he helped launch UK’s heart transplant program in the early 1990s) from private practice to serve as senior heart surgeon at the Gill. He saw the move to UK as an opportunity to advance the field of car-

Michael Sekela, MD, is a cardiac surgeon turned researcher whose stem cell protocol for regenerating weakened heart tissue is awaiting FDA approval.

diac surgery in a way he could not do in private practice. His years of operating on weakened hearts compelled him to consider innovative techniques to strengthen areas of heart tissue that were inducing heart failure.

Sekela saw the potential of harnessing a patient’s own stem cells to this end. The procedure involves removing stem cells from a patient’s bone marrow and injecting them into the weakened area via the left ventricle of the failing heart. Once stimulated with a laser, the stem cells begin to differentiate. Sekela explains, “The stem cells do not turn into heart muscle cells, rather blood vessel cells. This will increase blood flow to the area, which results in tissue regeneration and increased heart functionality.”

Under the Gill umbrella, Sekela says he has found everything he needs to bring his multidisciplinary project to fruition. “There are other physicians with stem cell experience, other physicians with heart failure experience, imaging technology, and imaging experts,” he says.

But, without nationally regarded stem cell researcher Abdel-Latif on staff, Sekela says his work would not have progressed as rapidly: “This hasn’t been done clinically anywhere else.”

The stem cell protocol is awaiting FDA approval. Following that, the initial local trial would take about two years. Should all go as planned, Kentuckians for whom everything has been tried, would have another option to increase the functionality of their failing hearts and improve the quality of their lives.

Exploring New Frontiers in the Cath Lab

Doing things no one else has could be the motto of John Gurley, MD, director of the Gill’s Interventional and Structural ISSUE#84 15

COVER STORY

John Gurley, MD, director of the Gill’s Interventional and Structural Heart Program, helped launch the Gill’s TAVR program.

16 M.D. UPDATE

Heart Program. The Gill’s cath labs, where MDs training to be interventionalists work side-byside with Gurley and others, is ground zero for advanced catheter-based therapies.

“In our role as an academic referral center, we see the most difficult and complicated cases every day,” says Gurley. “We’re a bit like the place where doctors come for solutions to problems no one else can fix. Sometimes, the solution can be accomplished with a needle-puncture.”

In addition to innovative clinical care, such as launching a regional transaortic valve replacement (TAVR) program, Gurley and partner Khaled Ziada, MD, director of the Cardiac Catheterization Laboratories at the Gill, serve as site-investigators on a number of high-profile clinical trials. The trials have brought important technology to UK that would otherwise not be available here. “Doctors here need a place with a culture that allows them intellectual freedom to think creatively and provides the tools to do complex work safely,” says Gurley. “This is where solutions to clinical problems are born so what doctors and hospitals do to improve the

health of the Commonwealth tomorrow is what we’re working on today.”

The Heart Institute of the Future is in Lexington Today

The success of the Gill rests on the attitudes and passions that are producing these bench-to-bedside success stories, but the Institute excels in other ways, too. The Gill has become a regional leader in outreach, developing relationships with regional providers like Appalachian Regional Healthcare System, Clark Regional Medical Center, and Georgetown Community Hospital, among others.

Smyth explains, “We are teaming with providers at the grass-roots level to keep patients close to home. In each community the approach is different because each community has a slightly different need. Our role as the academic medical center is not to duplicate heart care that is available closer to the patient’s home town, but provide the services for more complicated heart problems so that no patient ever has to leave Kentucky for cardiac care. That is better for the patient and more cost effective for everyone.” Smyth credits Rick McClure, coordinator of Outreach Services for the Gill, as the architect of this initiative.

National prominence is increasing in many ways. Awards have come to several doctors this year: Jacquie Noonan, MD, was named educator of the year by the American College of Cardiology; Mikel D. Smith, MD, will receive the Richard Popp Award for Excellence in Teaching at the meeting of the American Society of Echocardiography in June; and Fornwalt was the recent recipient of the prestigious National Institutes of Health Director’s Award, given to only a handful of extremely promising young investigators every year.

The commitment to translational science, the advocacy for communication, and the culture of innovation being cultivated at the UK Gill Heart Institute may be Kentucky’s best chance for reducing its heart disease mortality rate. Smyth and her senior staff, including Gill Administrator Justin Campbell, Head of Operations Kim Pennington, and Director of Inpatient Services Dr. Charles L. Campbell, are setting the standard for comprehensive heart care in our region. “Kentuckians have a lot to be proud of,” Smyth says. “And this program is among them.” ◆

SPECIAL SECTION  CARDIOLOGY/PULMONOLOGY

Raising the Grade

Dr. Jesse Roman helps grow UofL’s pulmonology programs to improve Kentucky’s lung health BY JENNIFER S. NEWTON F = Failing. That’s the grade Kentucky received in, not one, but all four categories of the American Lung Association’s (ALA) annual State of Tobacco Control Report in 2013.

The grades are based on four parameters: tobacco prevention, smoke free air policies, cigarette tax, and investments in smoking cessation programs. Though the grades essentially evaluate public policy and advocacy, according to Jesse Roman, MD, pulmonologist and chair of the Department of Medicine for the University of Louisville (UofL), a lack of tobacco control is directly related to the state of public health. “If you can’t control tobacco exposure, lung health will not be good,” says Roman.

From 2000-2004 Kentucky ranked highest in the nation in smoking-attributable lung cancer mortality rates. In 2006, Kentucky had the highest age-adjusted rate of lung cancer incidence in the nation and in 2011, the highest prevalence of chronic obstructive pulmonary disorder (COPD).

Kentucky also has a high rate of asthma and a below average rate of flu and pneumonia vaccine participation.

Roman came to UofL in 2009 from Emory University. While his main area of interest and expertise is lung fibrosis, his approach to improving lung health is systemic – from inpatient and outpatient clinical care, to research and clinical trials, to national public advocacy. Together with fellow UofL pulmonologist, Dr. Rafael L. Perez, Roman is responsible for establishing the Interstitial Lung Disease Program at UofL, which is a multidisciplinary team that includes thoracic surgeons, rheumatologists, lung pathologists, pulmonologists, nurses, and researchers.

One difficulty in the diagnosis and treatment of fibrosis is that many cases have no identifiable cause. For the most common of these disorders, known as idiopathic pulmonary fibrosis (IPF), there are no FDA-approved drugs known to improve

in excessive connective tissue deposition and scar formation or destruction of tissue with development of emphysema, among other abnormalities,” says Roman.

For Roman, lung remodeling, whether due to increased deposition or degradation of connective tissue, is the keystone of lung health. “We believe every disease of the lung, one way or another, is associated with remodeling of the lung,” says Roman. By understanding the remodeling process, Roman believes researchers can find a way to control it and therefore control disease. If that happens, the implications would reach far beyond just the lung.

“Understanding how the lung remodels will help us tremendously in understanding how other organs remodel,” says Roman.

PHOTO COURTESY UOF L.

LOUISVILLE

Dr. Jesse Roman is a pulmonologist and chair of the Department of Medicine for the University of Louisville whose work centers on lung remodeling.

outcomes, so access to clinical trials is critical for patients who fail standard methods of treatment. In fact, the Pulmonary Fibrosis Foundation just chose UofL as one of nine centers across the US for clinical trials and for the development of a National Patient Care Registry for Lung Fibrosis.

Study Guide

In addition to lung fibrosis, Roman’s research focuses on the effects of tobacco on lung tissue and the behavior of lung cells.

“Tobacco, chronic alcohol use, viral infections, asbestos exposure, and coal mining all can trigger inflammation and abnormal remodeling of the lung. This can result

The Improvement Equation

Over the past five years, UofL has worked to become a leader in respiratory health, establishing the only National Institutes of Health-supported program in the state for interstitial lung disease.

It also has specialized programs of excellence for cystic fibrosis for pediatric and adult patients in partnership with the Department of Pediatrics and sponsored by the Cystic Fibrosis Foundation. Other specialty areas include interventional pulISSUE#84 17

monology, sleep medicine, lung transplantation, chronic obstructive pulmonary disease, and black lung disease. In critical care, UofL has worked with units at the Robley Rex VA Medical Center, University Hospital, and Jewish Hospital to standardize respiratory care. UofL’s lung transplant program was waning when Roman arrived on campus but is now seeing a revival.

The program hired new staff, including a specialized lung pathologist, and now performs about 18-20 transplants a year with good outcomes. To accommodate overall program growth and public need, the number of pulmonology faculty at UofL has grown from six to 15 since 2009 thanks to Roman and the work of Dr. Rodney Folz who directed the UofL Pulmonary Division until early 2013.

Beyond clinical care are education and advocating for public health. One aspect of education is training the next generation of physicians in all of these specialty areas at the UofL School of Medicine. The UofL Division of Pulmonary, Critical Care and Sleep Disorders has accredited training programs in Pulmonary Medicine and Critical Care, as well as in Sleep Medicine; it recently opened a new program in Interventional Pulmonology.

In terms of advocacy, “We can take

care of patients, but at some point policy and public health have to be tackled,” says Roman. Roman and his colleagues give lectures in the community and around the country. They are also involved in national public advocacy. Roman chairs the Scientific Advisory Council for the Pulmonary Fibrosis Foundation, chairs a working group on lung fibrosis for the

pollution, and investing more money in cessation programs and prevention,” says Roman. The American Lung Association and other societies are hard at work in this area, he says.

He also emphasizes increased funding and education for simple public health issues such as flu shots and pneumonia vaccines, which will have an impact on a much

IF WE DON’T CONTROL TOBACCO, WE CAN’T CONTROL RESPIRATORY DISEASE. American Thoracic Society, and sits on the board of the American Lung Association/ Midland States. “Being a part of these national organizations is important because you begin to have a voice in health advocacy,” says Roman.

Fill in the Blank

Given all that is underway, Roman asserts there are still some items missing from the state’s lung health agenda. “We are missing a concerted effort at the legislative level to better control tobacco by increasing taxes on cigarettes, by promoting and investing more dollars in reducing air

larger population than individual patients seen in the clinic.

Roman challenges primary care physicians to make respiratory health a priority in their patient workups. Beyond respiratory rate, which does not catch every abnormality, there is not a good vital sign for lung health. Roman recommends physicians think about air pollution, work environment, and lifestyle factors and discuss them with their patients.

“Any effort we make today can only affect outcomes in decades,” says Roman.

“The later we start, the longer it’s going to take.” ◆

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18 M.D. UPDATE

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SPECIAL SECTION  CARDIOLOGY/PULMONOLOGY

Four-Part Harmony

Much like the four chambers of the heart, the KentuckyOne Health Heart Team works in unison for the betterment of patients

BY JIM KELSEY, PHOTOGRAPHY BY LIZ HAEBERLIN

A healthy heart has a beat and a rhythm all its own, four chambers working in unison to keep the life blood pumping.

It’s fitting, then, that one of the newest developments in the care and treatment of cardiac patients comes in the form of a fourperson physician team, working cohesively to perform the most intricate of procedures.

KentuckyOne Health features the first such team in Kentucky. The team consists of two cardiothoracic surgeons – Dermot Halpin, MD, FACS, and Hamid Mohammadzadeh, MD, FACS, – and two cardiologists – Michael Schaeffer, MD, FSCAI, and Nezar Falluji, MD, MPH, FACC, FSCAI. Together, the four physicians merge their specialties to bring expert care. They assess patients’ needs and candidacy for various procedures collectively and then LEXINGTON

perform those procedures as a team with the assistance of trained staff.

“At Saint Joseph, we’ve developed what I call a ‘Heart Team’ approach to caring for the cardiac patient,” Halpin says. “This unique team approach is a game changer, and it puts the patient at the heart of the matter.”

The team performed its first procedure together on July 7, 2013 at Saint Joseph Hospital, but the genesis for this team approach began a few years ago. As advancements in technology have led to more minimally invasive heart surgery (MIHS), such as transaortic valve replacement surgery (TAVR), the lines between cardiothoracic surgeons and cardiologists have become blurred.

The FDA mandated that before a patient could receive a percutaneous heart ISSUE#84 19

valve, two heart surgeons had to separately evaluate the patient and agree that the patient was a high risk for traditional heart surgery. The FDA also requires that a surgeon and a cardiologist be present at the same time during the procedure.

After evaluating other programs and seeing what worked and what did not, the Saint Joseph team determined that a fourphysician approach represented the ideal balance of opinions and most cohesive system in the operating room.

Taking the blending of specialties even further, the physicians actually rotate roles in the operating room. One physician puts in the pacemaker, one puts in the catheter that squirts dye into the aorta, a third pulls in the valve and holds it in position, and the fourth blows up the balloon, which inflates the valve. Rotating the roles enhances the overall expertise of the entire team.

“What we emphasize in our team – which is unique in this town and to our team – is that we actually exchange roles,” Falluji says. “So at the time of the procedure every one of us will do one step within that procedure and we rotate that role. Each and every one of us has performed a portion of that procedure and we do that in sequence.”

“Cardiology and Cardiac Surgery have always worked together, but only recently have we found ourselves side-by-side in the catheterization lab, operating room, and specialty clinics,” Schaeffer adds. “It is clear to us, that the skills of Interventional Cardiology and Cardiac Surgery complement each other well for these complex patients. It’s likely that future hybrid procedures will follow the same path.”

Saint Joseph Hospital introduced the first hybrid suite in the state nine years ago, and it has allowed the heart surgeons and cardiologists to treat the patient together in a procedure for the first time in the history of the two specialties. But the teamwork actually begins long before the procedure occurs. The process of assessing a patient begins with all four members of the “Heart Team” evaluating the patient independently.

Then they discuss their findings and reach a conclusion as to whether the valve needs to 20 M.D. UPDATE

be dealt with and whether or not the patient is a surgical or percutaneous procedure candidate.

Optimal Patient for TAVR

The ideal candidate for TAVR is a patient with severe, symptomatic aortic valve stenosis, determined to be high-risk for surgical valve replacement, with an expectation of living at least one year if their heart valve can be replaced. This assessment is made based on other medical problems, previous open heart surgery, and overall degree of frailty. Before TAVR many of these patients have been advised, correctly, that there was nothing else that can be done for them. Some may not have had their options reconsidered since the availability of TAVR. The best candidates also have no significant peripheral artery blockages so they can

(L TO R) Dr.

Hamid Mohammadzadeh, Dr. Nezar Falluji, Dr. Michael Schaeffer, and Dr. Dermot Halpin make up KentuckyOne Health’s four-person “Heart Team” at Saint Joseph Hospital.

undergo the transfemoral approach, which is the least invasive of the TAVR approaches with the best outcomes.

“We have patients declined TAVR due to multiple, severe medical problems such that we don’t expect them to live more than one year, even if we have a successful valve procedure,” says Schaeffer. “We have also had to decline a few patients with aortic valve anatomy that was too large for the two

currently available TAVR valve sizes. This will not be a problem with the expected approval of larger valve sizes in the near future.”

Patient Betterment

The real payoff of the MIHS and the team concept is that many patients who would not have been surgical candidates a few years ago are now not only able to

Cardiologist Dr. Nezar Falluji scrubs in to participate in a TAVR procedure in a hybrid operating room.

receive treatment, but are leaving the hospital in a matter of days instead of weeks.

“We’re dealing with a general population that we have never encountered,” Mohammadzadeh says. “These are the patients that the cardiologists cannot help, and they are also considered to be very high risk for us to take care of them.

“Before, in order to fix an aortic valve stenosis, we had to have a very invasive approach, which involved cutting the chest and stopping the heart and cutting the heart open and cutting out the old valve and putting in the new valve, which took a significant toll on the patient. With these new technologies, frequently these valves can be fixed with two little incisions in the groin or the valves can be fixed by a small incision on the side of the chest.

Overall, the patients do remarkably better after this procedure. We see people leaving the hospital in four days at the most,” says Mohammadzadeh.

In addition to the core team of physicians at KentuckyOne Health Cardiology

The Edwards SAPIEN Transcatheter Heart Valve™ is placed onto the catheter and inserted into a crimper to prepare for implantation.

RIGHT: The heart valve is attached to the catheter and ready for implantation.

ABOVE:

ISSUE#84 21

The four-person team, made up of two cardiologists and two cardiac surgeons, work side-by-side and rotate roles in the OR.

of success and elite standards for the overall well-being and quality of life for their patients.

“We have a tradition in this hospital of caring for patients with heart disease,” Halpin says. “The high-risk patients are doing well not because we’re lucky, but because we’re cohesive. We put our egos out, and we work as a team. The complexity of the patients that we now see in this structural heart clinic mandates that you have a team approach that will put the patient at the heart of the matter.” ◆

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Associates and KentuckyOne Health Cardiothoracic Surgery Associates, investments have been made, including a PhD in Nursing Valve Coordinator position – currently held by Tara Blair – who is dedicated purely to the structural heart team. Blair works with the doctors to send the patients home with a rehabilitation and recovery program.

“These patients are decisively treated, and they don’t need significant subsequent follow up. They can be managed by their own local cardiologist and primary care physician,” Falluji says. “Our patients are now offered an opportunity for decisive therapy for something that was deemed before as inoperable or high risk and came with a significant tax of complications.”

Less than a year removed from their first team operating effort, the Heart Team is committed to maintaining high levels

SPECIAL SECTION ď ľ CARDIOLOGY/PULMONOLOGY

Minimally Invasive Hybrid Coronary Revascularization LIZ HAEBERLIN

BY NEZAR FALLUJI, MD, FCCS, DERMOT P. HALPIN, MD, FACS Cardiac Surgery and Interventional Cardiology are collaborating to provide patients minimally invasive coronary artery bypass techniques (CABG) at Saint Joseph Hospital in Lexington Kentucky. A hybrid strategy combines the treatments traditionally only available in the operating room with those only available in the cath lab.

As the baby boomers age, the risk profile of patients referred for CABG worsens. Older patients with a high incidence of diabetes, renal failure, hypertension, stroke, and COPD represent the typical patient cohort referred for CABG. Hybrid coronary revascularization (a combination of PCI/stent to the right coronary artery and/or circumflex coronary artery with minimally invasive left internal mammary artery to the left anterior descending artery) avoids a sternotomy.

The LIMA patency rate of 95 to 98 percent at 10 years provides a survival benefit to each patient. This is the premise on which Hybrid CABG is based. The rational for Hybrid CABG is based on the fact that drug eluting stents and vein bypass grafts to nonLAD territories appear to have comparable

Nezar Falluji, MD, FCCS, is a cardiologist with KentuckyOne Health Cardiology Associates Lexington, Kentucky.

RIGHT Dermot P. Halpin, MD, FACS, is a cardiothoracic surgeon with KentuckyOne Health Cardiothoracic Surgery Associates in Lexington, Kentucky.

patency rates. Minimally invasive LIMA, the LAD Bypass is performed through a small sub mammary incision (5 to 7 cm).

This is less traumatic for the patient and provides a faster recovery time. Indications for Hybrid CABG include proximal LAD lesion with favorable lesion for PCI in the right coronary artery and circumflex coronary arteries. Contraindications include body mass index greater than 35, intra muscular LAD and a left subclavian occlusion, or prior thoracic surgery.

Other Hybrid surgeries being per-

formed at Saint Joseph Hospital included Percutaneous Valve (TAVR), Mitral Clip procedure, and Hybrid Aortic Arch Debranching procedure for Thoracic Aneurysms.

The results for Hybrid revascularization are safe with a low mortality rate; low morbidity rate; shorter ICU stay; and shorter hospital stay with a faster recovery. We believe this team approach with the Interventional Cardiologist and Heart Surgeon working closely together provides better patient care and outcomes. â—†

KentuckyOne Health Cardiology Associates (859) 276-4429 KentuckyOne Health Cardiothoracic Surgery Associates (859) 278-2334

2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober ts@barcpa.com www.barcpa.com

ISSUE#84 23

COMPLEMENTARY CARE

Time to Quit

Floyd Memorial forms Community Coalition to promote smoking cessation and prevention

BY JENNIFER S. NEWTON

County Health Department, the New Albany Housing Authority, the American Cancer Society, pharmacists, and behavioral health professionals. The Coalition is funded by the Indiana State Department of Health Tobacco Prevention and Cessation Commission and the Floyd Memorial Hospital Foundation.

While Kentucky is in the process of trying to pass a statewide smoking ban, Indiana has already enacted a Smoke Free Air Law, which took effect in 2012. For Floyd Memorial Hospital & Health Services (FMHHS) in New Albany, Indiana, the law was a start, but FMHHS’ 2013 Community Health Needs Assessment for Floyd County FMHHS’ Tobacco Coalition emphasized an ongoing need for smoking has four primary initiatives: cessation and prevention in the community. 1. To change public policy.

The assessment evaluated 150 health 2. To integrate smoking cessation strategies indicators to determine where resources are into hospital electronic medical records most needed. To create a workable action (EMR). plan, FMHHS chose to focus on three of 3. To implement a grant program that the largest health priorities: heart disease, provides free facilitator kits for the Cooper obesity, and cancer, particularly colon, breast, and lung cancers.

That action plan included creating three Community Coalitions in the areas of Physical Activity, Nutrition, and Tobacco Cessation and Prevention.

According to the Community Assessment, Floyd County’s incidence of tobacco use, nearly 30 percent, is above the national average. Shannon Carroll, RN, BSN, coordinator of Floyd Memorial’s Healthier Community Initiative, says, “Every indicator for lung health – asthma in impoverished children, lung cancer, pneumonia deaths – is linked to high tobacco use.” The report found correlations in indicators between these high priority health issues: “The incidence of Lung Cancer Shannon Carroll, RN, is linked to many other cancers.

BSN, is coordinator It also has direct correlation with of Floyd Memorial’s lifestyle choices, specifically smokHealthier Community ing. Smoking correlates with lung Initiative. cancer, pre-term and low birth weight babies, and heart disease.”

The Tobacco Cessation and Prevention Clayton Smoking Cessation program to 10 Community Coalition is made up of businesses and/or community sites.

15 to 20 community members, includ- 4. To educate college students, a critical poping FMHHS staff, physicians, the Floyd ulation, on the adverse effects of smoking.

NEW ALBANY, IN

FLOYD MEMORIAL

24 M.D. UPDATE

Of the first goal, Carroll says, “You get positive movement on smoking cessation when you change public policy.” The coalition is developing a strategic plan to expand local legislation beyond state law.

In terms of EMR, the hospital has completed integration with their system. The nursing assessment for every patient now includes two questions: 1) Do you use tobacco? and 2) Would you like free help to quit? If the answers are yes, patient contact information is automatically sent to Indiana’s Tobacco Quitline, 1-800-QUIT-NOW. The Quitline is funded by the master tobacco settlement agreement and offers free behavior management counseling sessions over the phone. Depending on insurance, participants also typically get about two weeks’ worth of nicotine replacement for free. The drawback is each participant only gets a limited number of sessions. “It is good as an initial intervention but somewhat time-limited,” says Carroll. “So the Coalition wants to expand those resources.”

FMHHS will begin offering a Cooper Clayton smoking cessation course to the community in 2014, but the Coalition is taking it a step further. While the Cooper Clayton program is free, the kit for those facilitating the course costs $200. The Coalition has purchased 10 facilitator kits and is implementing a grant program for local businesses/organizations that want to offer the program to their employees.

Additionally, the Coalition is working with local pharmacies to provide reduced cost nicotine replacement.

Finally, the Coalition is targeting an important population of potential new smokers – college students at Indiana University Southeast. The group has funded a national online monthly health and wellness magazine that features at least one smoking-related article each issue for students.

With a multi-pronged approach, FMHHS’ Tobacco Coalition is primed to meet the state’s goals for reducing tobacco use in Floyd County in 2015. ◆

COMPLEMENTARY CARE

LOVE SICK:

An Unhappy Marriage Can Be Hazardous to Your Patient’s Health DR. JAN ANDERSON Does the quality of a patient’s romantic relationship affect the quality of his or her health? Thanks to the work of researchers like Lois Verbrugge and James House, both of the University of Michigan, we now know that an unhappy marriage can increase a patient’s chances of getting sick by 35 percent and even shorten their lives by an average of four years. The flip side: People who are happily married live longer, healthier lives than either divorced people or those who are unhappily married. Scientists know for certain that these differences exist, but we are not sure why.

According to marriage researcher John Gottman, PhD, part of the answer may be that in an unhappy marriage people experience chronic, diffuse physiological arousal, which can present itself in physical ailments, including colds, flu, high blood pressure, and heart disease. “Not surprisingly, happily married couples have a far lower rate of such maladies,” according to Gottman. “They also tend to be more health-conscious than others. Researchers theorize that this is because spouses keep after each other to have regular checkups, take medicine, eat nutritiously, and so on.”

Not only do happily married people avoid this drop in immune function, but their immune systems may even be getting an extra boost. Subjects who were satisfied with their marriages showed a greater proliferation of white blood cells when exposed to foreign invaders, as well as more effective natural killer cells, than did other test subjects.

For patients that may be unaware of the toll relationship stress is taking on their health, their physician can take a proactive approach and recommend a consultation with a relationship counseling professional to explore relationship practices that may improve the patient’s chances of responding well to medical treatment. Fortunately, those of us specializing in the area of relationship counseling now have more evidence-based methods than ever before to help our clients develop the delicate balance

Dr. Jan Anderson is a Licensed Professional Clinical Counselor with a Doctorate in Clinical Psychology.

Her private practice includes over 15 years of experience counseling individuals, couples, and families.

between “accentuate the positive, but don’t eliminate the negative.”

1. Accentuate the positive

In his ground-breaking book Why Marriages Succeed or Fail, John Gottman’s research suggests that what really separates contented couples from those in deep marital misery is a healthy balance between their positive and negative feelings and actions toward each other. According to Gottman, “There is a very specific ratio that exists between the amount of positivity and negativity in a stable marriage. That magic ratio is 5-to-1. As long as there is five times as much positive feeling and interaction between husband and wife as there is negative, we found the marriage was likely to be stable.” One of the most gratifying aspects of my work as a relationship counseling professional is to see the effect of evidence-based practices that help couples rediscover, reclaim, and cultivate the ability to express a genuine interest in each other’s lives and communicate affection, fondness, and admiration for each other.

cism or contempt. He says, “A relationship can actually be strengthened because embedded in the complaint is the message that the complaining partner wants the relationship to get back on course so it can continue.” In my own practice of relationship counseling, I have been amazed at how much “straight talk” the partner is able to hear when the complainer feels free to be open without fear of losing the other’s affection.

Patients may assume that their relationship issues will resolve themselves without professional attention, often at the expense of their health, their wellbeing, and their marriage. By developing collaborative relationships with relationship counseling professionals, physicians can take a multidisciplinary approach to treat patients suffering relationship stress and associated health issues – and enhance the perceived competency of both providers. ◆

2. But don’t eliminate the negative

Gottman originally assumed that expressing anger would have a destructive effect on a couple’s relationship but was surprised to find that complaining is actually one of the healthiest activities that can occur in a marriage. Expressing anger and disagreement, rather than suppressing the complaint, appears to make the marriage stronger in the long run. Gottman reports that anger appears to negatively affect the marriage only when it is defensive or expressed with critiISSUE#84 25

NEWS  EVENTS  ARTS

Kaplan Joins Baptist Gastroenterology Associates

Mitchell Kaplan, MD, has joined Baptist Gastroenterology Associates, part of Baptist Medical Associates, Louisville. He is boardcertified in gastroenterology.

LOUISVILLE

Kaufman Joins Louisville Cardiology Group Tara Kauffman, APRN, has joined the Louisville Cardiology Group (part of Baptist Health Medical Associates) as a nurse practititioner.

LOUISVILLE

Williams Named Director of UK Center for Health Services Research

Dr. Mark V. Williams, the new director for the University of Kentucky Center for Health Services Research, has a clear vision for the multidisciplinary research center: Applying research to optimize care.

Williams joins UK’s continued efforts on quality improvement and outcomes research. The Center for Health Services Research (CHSR) is focused on creating, testing, and scaling next-generation solutions to improve the efficiency and effectiveness of health care delivery and the overall health of people within Kentucky and beyond. A primary objective of the center is to accelerate the discovery of new knowledge concerning clinical effectiveness and cost-effectiveness of health care delivery, particularly in rural and limited-resource settings.

Health services and outcomes research is LEXINGTON

26 M.D. UPDATE

SEND YOUR NEWS ITEMS TO M.D UPDATE > news@md-update.com

an evolving priority area for UK. With the recruitment of Williams and his research team, UK adds significant clinical informatics expertise and depth to the biomedical informatics capacity already housed within the UK Center for Clinical and Translational Science.

Under Williams’s leadership, the CHSR will strive to translate research findings into improved decision-making in the clinics, conference rooms and administrative offices of UK HealthCare.

Williams brings to the Center a wealth of clinical and research expertise. He most recently served as the chief of the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine in Chicago. A graduate of the University of Florida and Emory University School of Medicine, Williams completed an internship and his residency in internal medicine at Massachusetts General Hospital. He also completed postdoctoral training at the General Medicine Faculty Development Fellowship Program of the University of North Carolina - Chapel Hill, the Woodruff Leadership Academy, the Harvard Palliative Care Education Program, the Advanced Training Program in Quality Improvement at the University of Utah, and obtained a Lean Certification from Simpler Consulting Inc.

Rinker Wins Award for Paper Highlighting New Post-Mastectomy Surgery Technique

The American Society of Plastic Surgeons recently awarded UK HealthCare’s Dr. Brian Rinker a “Best Paper” designation for his contribution to Plastic and Reconstructive Surgery.

The “Best Paper” awards are determined by the number of views and downloads the articles receive. Rinker’s article, “The Use of Dermal Autograft as an Adjunct to Breast Reconstruction with Tissue Expanders,” highlighted a new and safer way to reconstruct breast cancer patients following a mastectomy. As a surgeon who specializes in breast reconstruction in UK’s Division of Plastic Surgery, Rinker frequently colLEXINGTON

UK’s Dr. Brian Rinker (left) accepts his “Best Paper” award at the American Society of Plastic Surgeons’ conference in San Diego.

laborates with the UK Markey Cancer Center’s surgical oncologists to provide a full spectrum of surgical care for mastectomy patients.

“The procedure introduced in the paper is a step forward in the care of breast cancer patients, as it produces an aesthetically pleasing reconstruction with a lower risk of infection and wound healing problems,” Rinker said. “UK is the only center in the region to offer the full range of breast reconstruction procedures, including microsurgical reconstruction, and this procedure is yet another option for our patients.”

The UK Markey Cancer Center is the only National Cancer Institute-designated cancer center in Kentucky. NCI-designated cancer centers are a major source of discovery and development of more effective approaches to cancer prevention, diagnosis and treatment. 

Wilcock Appointed Associate Editor of the Journal of Neuroscience

Donna Wilcock, assistant professor in the University of Kentucky College of Medicine Department of Physiology and the UK Sanders-Brown Center on Aging, has been invited to join the editorial board of The Journal of Neuroscience in 2014 as an associate editor in the Neurobiology of Disease section.

LEXINGTON

Bastos-Carvalho Receives Bayer Grant

Ana Bastos-Carvalho, a visiting scholar in the Ambati research group LEXINGTON

Direct Access: Plug Into D. Scott Neal’s Expertise in the Department of Ophthalmology and Visual Sciences at the University of Kentucky College of Medicine, Ana Bastos-Carvalho received the Global Ophthalmology Research Award from Bayer HealthCare for her research, “Mechanisms of geographic atrophy expansion in age-related macular degeneration.” http://www.bayer-ophthalmology-awards.com/html/b-about-c.html “We are studying age-related macular degeneration (AMD), the disease responsible for most cases of legal blindness in the American elderly population”, BastosCarvalho said. “The project awarded by Bayer focuses on unraveling how AMD progresses, which will hopefully lead to new therapies to stop the relentless and untreatable evolution of the disease.”

In 2012, Bayer HealthCare launched the Global Ophthalmology Awards Program (GOAP) with the aim of advancing the scientific understanding and clinical management of retinal ophthalmic disorders. Bayer envisions the GOAP as a step toward making the dream of ophthalmology cures and improved treatments a reality.

With D. Scott Neal’s financial planning and guidance, you have direct access to the power of his knowledge and the energy of his wealth management philosophy.

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Leadership Changes Announced by Cardiovascular Innovation Institute

Laman Gray, MD, a pioneer in heart disease research and the development and use of cardiovascular assist devices and artificial organs, has been named executive director of the Cardiovascular Innovation Institute. Gray will continue in his role as medical director of CII. Roberto Bolli, MD, has been named the scientific director and Stuart Williams, PhD, has been named the director of bioficial organ research. The leadership positions were announced following a meeting of the CII Board of Directors.

In 2003 the University of Louisville and Jewish Hospital & St. Mary’s HealthCare partnered to create the CII, bringing together some of the finest minds in the LOUISVILLE

A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include:

ISSUE#84 27

NEWS field with the goal of improving the quality of life for patients with cardiovascular disease. The CII builds on the success of both organizations’ previous efforts to combat heart disease and heart failure through the development of novel treatments and therapies including adult stem cells, ventricular assist devices, artificial hearts and much more. The chair position of the CII board alternates annually between a designee of the Jewish Heritage Fund for Excellence and the University of Louisville.

Gray is internationally known as a leader in the fields of artificial hearts and circulatory support systems. He performed the first heart transplant in Kentucky in 1984. In 2001, his surgical team implanted the first fully implantable replacement heart, the AbioCor™. He served as director of University of Louisville School of Medicine’s Thoracic and Cardiovascular division for over 33 years. In 2008, he was awarded the University of Kentucky Medallion for Intellectual Achievement, which recognizes high intellectual achievement by Kentuckians.

Bolli is a leader in regenerative cardiology, the pioneering use of patient-derived cardiac stem cells to repair heart muscle damaged during a heart attack. He recently received the Research Achievement Award from the American Heart Association “for the profound and lasting impact of his extraordinary contributions to cardiovascular research.”

Williams joined the CII in 2007. His research interests have focused on medical devices, regenerative medicine and infection control. He developed and patented the first methods to use fat-derived stem cells for therapeutic use.

New Therapy at Jewish Hospital Helps Patients With Serious Stomach Disorder Linked To Diabetes

A new complication for the rapidly growing U.S. diabetes population[i] may be the significantly increased risk of gastroparesis,[ii] a serious digestive disorder which is estimated to affect five to 12 percent of the diabetes population.[iii] Jewish Hospital, part of KentuckyOne Health, is the only medical center in Louisville offering Medtronic Enterra® Therapy, the first and only FDA-approved* gastric electriLOUISVILLE

28 M.D. UPDATE

cal stimulation therapy indicated for use in the treatment of chronic, intractable (treatment-resistant) nausea and vomiting associated with gastroparesis of diabetic or unknown origin.

In patients with gastroparesis, a disorder in which food moves through the stomach more slowly than normal, the stomach muscles work poorly (or not at all), thus preventing the stomach from emptying properly.

Symptoms of gastroparesis include nausea and vomiting, and may include abdominal bloating and pain, lack of appetite and excessive weight loss. These symptoms prevent a person from eating normally and may lead to dehydration and malnutrition.

Although there is no cure for gastroparesis, therapies like Medtronic Enterra Therapy may improve symptoms of chronic nausea and vomiting when conventional drug therapies are not effective or tolerated.

“Medtronic Enterra Therapy is an important part of the treatment landscape for my patients with gastroparesis,” said Thomas Abell, MD, director of the Jewish Hospital GI Motility Clinic and the Arthur M. Schoen, MD, chair in Gastroenterology at the University of Louisville. “Gastroparesis is difficult to manage, and given the enormity of the diabetes epidemic particularly in Kentucky additional therapeutic options to manage the symptoms associated with this disorder are critical.”

Jewish Hospital implanted its 100th temporary gastric electrical stimulation therapy device in December 2013. The temporary device is implanted first to be sure the therapy is effective before a permanent device is placed.

New UK Study Shows Potential for Targeting Aggressive Breast Cancers

A new study led by University of Kentucky Markey Cancer Center researcher Peter Zhou shows that targeting Twist, a nuclear protein that is an accelerant of the epithelial-mesenchymal transition (EMT) program in human cells, may provide an effective approach for treating triple-negative breast cancer.

Published in Cancer Cell, the study found that the nuclear protein Twist acts similarly to a virus protein. Using protein purification, Zhou’s team identified that LEXINGTON

Researcher Peter Zhou

Twist interacted with a key nuclear transcription regulator BRD4. When many DNA viruses (such as papillomaviruses) enter into human “host” cells during infection, they hijack host cell machinery to replicate and synthesis their viral DNA and proteins. BRD4 is the virus’s favored molecule and is often seized by DNA papillomaviruses for gene transcription during replication and growth.

Twist uses a similar strategy to recruit BRD4 to the genomic regions that are regulated by Twist. Many of these genomic regions contain oncogenes, such as those of survival proteins, growth factors and molecules that enhance cell migration and invasion. By recruiting BRD4 to these genomic regions, Twist accelerates cell growth and invasion by “waking up” the expression of these oncogenes.

Additionally, the study showed that two BRD4 inhibitors, JQ1 and MS417, can specifically disrupt the interaction of Twist with BRD4, resulting in the suppression of invasion, stem cell-like characters and tumorigenicity of triple-negative breast cancer cells.

Jian Shi, a post-doctoral fellow at UK Markey Cancer Center, was the first author of this study, and other collaborators include UK Markey Cancer Center director Dr. Mark Evers and researchers Chi Wang and Haining Zhu. Previously, Zhou and his team have studied the role of the Snail complex — also known as the cellular “brake” in contrast to Twist’s accelerant — in the EMT program.

UK Gill Heart Institute, Whitesburg’s MCHC, ARH Cardiology Associates Join Forces to Provide Heart Care

Letcher County community leaders and health care providers gathered in Whitesburg on Jan. 23 to celebrate a new partnership among Mountain Comprehensive Healthcare Corporation (MCHC), Appalachian Regional Healthcare (ARH), and UK HealthCare’s Gill Heart Institute.

Dena Sparkman, CCEO of Whitesburg ARH, welcomed more than 100 invited WHITESBURG

NEWS guests to the event held at the Pine Mountain Grill in Whitesburg. Remarks were provided by Joe Grossman, president and CEO of Appalachian Regional Healthcare; University of Kentucky Vice President for Health Affairs Dr. Michael Karpf; Mike Caudill, CEO at MCHC; Dr. Van Breeding, MCHC director of clinical affairs; and Dr. Susan Smyth, chief of cardiovascular medicine at the Gill Heart Institute.

Beginning earlier this month, ARH Cardiology Associates, in affiliation with UK Healthcare’s Gill Heart Institute, began offering cardiology services at MCHC in Whitesburg, allowing patients the ability to stay close to home for the highest quality and state-of-the art cardiovascular care.

ARH and UK HealthCare’s Gill Heart Institute joined forces last year in a collaboration aimed at improving access to UK’s expertise and resources offered by a regional academic medical center while maintaining the familiarity of community health care providers.

Mountain Comprehensive Health Corporation (MCHC), is a Federally Qualified Health Center designed to provide quality, affordable health care to the people of Letcher, Harlan, Perry, Owsley, and contiguous counties, and has been in operation since June 1971. MCHC is a non-profit Kentucky Corporation.

(L TO R) Mike

Caudill, Dr. Van Breeding, Dr. Michael Karpf, Dena Sparkman, Dr. Susan Smyth, and Joe Grossman

MCHC’s Central Office, Whitesburg Medical Clinic, Respiratory Clinic, and Wellness Center are located in Whitesburg.

The Buckhorn and the Leatherwood/ Blackey Medical Clinics are located in Perry County, the Harlan Medical Clinic is in Harlan near the Harlan ARH Hospital, and the Owsley County Medical Clinic is located in Booneville. The Buckhorn, Leatherwood/Blackey and Owsley County Clinics each provide a Wellness Center for their patients. MCHC also operates 16 ISSUE#84 29

NEWS school-based clinics in Letcher and Perry counties. 

UofL Named as One of Nine Centers in U.S. for Pulmonary Fibrosis Research LOUISVILLE The

University of Louisville is one of nine pilot sites selected by the Pulmonary Fibrosis Foundation (PFF) for its newly established Care Center Network and the PFF Patient Registry program. Rafael Perez, MD, director of the UofL Interstitial Lung Disease (ILD) program in the Division of Pulmonary, Critical Care & Sleep Disorders Medicine, will lead the UofL site.

Aimed at improving the health and quality of life of patients suffering from pulmonary fibrosis, the network and registry will help provide critical insights enabling the medical research community to develop more effective therapies, say UofL physicians involved in the initiative.

Sites were selected because of their expertise in pulmonary fibrosis patient care and research. In the network with UofL are the University of California, San Francisco, University of Chicago, University of Michigan, National Jewish Health, University of Pittsburgh, Vanderbilt University, University of Washington and Yale University.

The PFF Care Center Network will provide a standardized, multidisciplinary approach to patient care. This model of comprehensive patient care will help identify and establish best practices, determine the impact of specific interventions, and improve the quality of life of patients. The Care Center Network will incrementally expand to eventually include 40 medical centers by 2015.

The PFF Patient Registry is planned to be the largest database of PF patient records with the furthest demographic reach in the country. It will provide data essential for improving the understanding of the epidemiology, incidence, prevalence, natural history, and other clinical characteristics of PF. The registry will use consistent data-gathering methodology so that the information obtained will be useful to all clinicians and researchers seeking to better understand the disease and develop new therapies for PF. All the pilot sites of the Care Center Network will participate in the Patient Registry. A principal investigator at each 30 M.D. UPDATE

network site will work with a team of allied health professionals to enroll PF patients into the Registry. The Duke Clinical Research Institute at Duke University will host and maintain and oversee implementation of the PFF Patient Registry.

Patients needing treatment for pulmonary fibrosis should contact Perez at University of Louisville Physicians, 502813-6500. For more information about the PFF, visit www.pulmonaryfibrosis.org.

Exhaled Breath May Help Identify Early Lung Cancer

Specific compounds found in exhaled breath may help diagnose lung cancer in its early stages, according to a study released at the 50th Annual Meeting of The Society of Thoracic Surgeons.

The discovery was made when Associate Professor of Cardiovascular and Thoracic Surgery Michael Bousamra, MD, and other researchers from the University of Louisville examined patients with suspicious lung lesions.

Using a silicone microprocessor developed at UofL and a mass spectrometer, the researchers tested exhaled breath for specific volatile organic compounds (VOCs) known as carbonyls from patients with suspected lung cancer detected on computed tomography scans. The researchers then matched their findings with pathologic and clinical results.

“Although the data are preliminary, we found that patients with an elevation of three or four cancer-specific carbonyl compounds was predictive of lung cancer in 95 percent of patients with a pulmonary nodule or mass,” Bousamra said. “Conversely, the absence of elevated VOC levels was predictive of a benign mass in 80 percent of patients.”

The researchers found that elevated carbonyl concentrations returned to normal following complete resection – surgical removal – in patients who had a malignant nodule.

“Instead of sending patients for invasive biopsy procedures when a suspicious lung mass is identified, our study suggests that exhaled breath could identify which patients may be directed for an immediate intraoperative biopsy and resection,” Bousamra said.

The silicone microprocessor used in the LOUISVILLE AND ORLANDO, FL

study was developed at the University of Louisville. It was coated with an amino-oxy compound that binds to carbonyl compounds in exhaled breath.

UofL Epidemiologist Uncovers New Genes Linked to Abdominal Fat

Excess abdominal fat can be a precursor to diseases such as cardiovascular disease, type 2 diabetes, and cancer. A person’s measure of belly fat is reflected in the ratio of waist circumference to hip circumference, and it is estimated that genetics account for about 30-60 percent of waistto-hip ratio (WHR). Kira Taylor, PhD, MS, assistant professor, University of Louisville School of Public Health and Information Sciences, and her research team have identified five new genes associated with increased WHR, potentially moving science a step closer to developing a medication to treat obesity or obesity-related diseases.

The researchers recently published their findings in Human Molecular Genetics.

The team conducted an analysis of more than 57,000 people of European descent, and searched for genes that increase risk of high waist-to-hip ratio, independent of overall obesity. They investigated over 50,000 genetic variants in 2,000 genes thought to be involved in cardiovascular or metabolic traits.

Their analysis identified three new genes associated with increased WHR in both men and women, and discovered two new genes that appear to affect WHR in women only. Of the latter, one gene, SHC1, appears to interact with 17 other proteins known to have involvement in obesity, and is highly expressed in fat tissue. In addition, the genetic variant the team discovered in SHC1 is linked to another variant that causes an amino acid change in the protein, possibly changing the function or expression of the protein.

Prior research has found that mice lacking the SHC1 protein are leaner, suggesting this molecule may have a role in metabolic imbalance and premature cell deterioration by supplying too much nutrition for normal growth and development.

Additional evidence finds SHC1 activates the insulin receptor, triggering multiple signaling events that affect fat cell growth. ◆ LOUISVILLE

EVENTS

LEFT TO RIGHT:

Charles Barton, MD, Krista Preston, MD, David Keedy, MD, Shelley Stanko, MD, Peter McKeown, MD, Sathyendra Mysore, MD, Kristin Moore, MD Aqeel Mandviwala, MD.

Saint Joseph London Foundation hosts Masquerade Ball

The Saint Joseph London Foundation’s 2014 Affair of the Heart: Masquerade Ball on February 1, 2014, raised over $40,000 to benefit over 2,500 patients and families through the Healthy Communities program.

LONDON

Installing New Officers

The new officers of Lexington Medical Society (LMS) were installed at the meeting on January 14, 2014. Thomas H. Waid, MD, president, David S. Kirn, MD, vice-president, Jason P. Harris, MD, LEXINGTON-

secretary-treasurer, Rice C. Leach, MD president–elect, Richard D. Floyd, IV, MD, vice-president elect, and Charles L. Papp sec-treasurer elect.

Christopher Hickey was in attendance as the new Executive Vice President/CEO of the LMS succeeding Carolyn Kurz, who retired after many years of service to the LMS. The Lexington Medical Society’s Layperson Award was re-named The Carolyn Kurz Layperson Award. A retirement party honoring Kurz was held January 24 in Lexington.

Central Kentucky Heart Ball Comes to Lexington on Saturday, March 8

Each year, the American Heart Association hosts a party to celebrate its mission, volunteers, donors, and the lives saved from heart disease and stroke. It’s a night to reflect on the past accomplishments and achievements, as well a look toward the future ones.

The Central Kentucky Heart Ball will be held on Saturday, March 8 at Lexington Center’s Bluegrass Ballroom. Now in its 26th year, this black tie event has helped to advance the lifesaving mission that has impacted the lives of thousands of men, women, and children in the Lexington area.

Corporate and medical professionals will gather to honor survivors and those who made major contributions in cardiovascular research. This year’s ball is chaired by Darby and Charlotte Turner and will honor Warren W. Rosenthal for his community-wide achievements. Guests will enjoy fine dining, dancing, and unique silent and live auction opportunities. All proceeds from the Heart Ball will support the American Heart Association, which LEXINGTON

John G. Roth, MD, and Clifton W. Smith, MD, Kentucky Dermatology & Cosmetic Surgery Center attended the January installation of new officers meeting of the Lexington Medical Society.

Cameron S. Schaeffer, MD, Melissa M. Avery, MD, MMM, Bluegrass Family Health and David S. Kirn, MD, came out on a cold January night to support their Lexington Medical Society.

funds public and professional education, advocacy, and scientific research.

“This is one of our largest and most important events,” said Mike Turner, special events director for the American Heart Association. “Our survivors will be honored and their physicians spotlighted for their significant lifesaving achievements, which allow the community, donors, and supporters to see the results of the American Heart Association’s research, advocacy, educational programs, and dedication at work.”

Tickets start at $200 per person with proceeds benefiting the American Heart

The Heart Ball will also feature internationally acclaimed Metropolitan Opera Star Gregory Turay.

Association. For more information, call Mike Turner at (859) 977-4605 or visit www.heart.org/LexingtonKYHeartBall.

Lexington Art League's Art Ball

Over 350 supporters of the arts braved frigid temperatures on January 25 to celebrate “Luminosity” at the Lexington Art League’s Art Ball. Guests were treated to an exclusive preview of the exhibition’s signature piece – a 20-ft. sculpture made of repurposed light bulbs collected via a community light bulb drive. The sculpture, called “New Moon,” will be revealed to the public on Feb. 21st at Triangle Park, where an interactive element will be unveiled for the first time. ◆

Enjoying the gala were Ted Wright, MD, and wife Saskia Wright, Gil Dunn, M.D. Update, Christine and Davanand Doodnauth, MD. PHOTO BY NEIL SULIER

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ARTS tory over unbelievable odds––accomplished through conviction, perseverance, and love.

For tickets, call the Lexington Center Ticket office or Ticketmaster.com

The Miracle Worker Comes to Lexington

Interactive Sculpture to Grace Downtown Lexington

LEXINGTON

LEXINGTON

Few stories are as timeless or reveal the courage and resilience of the human spirit as well as The Miracle Worker, coming to the Lexington Opera House for five performances March 14 -16. Presented on the 2013-14 Broadway Live series and sponsored

by KentuckyOne Health, the stirring dramatization of the story of Helen Keller and her tutor Annie Sullivan has been mesmerizing audiences for decades. The Miracle Worker tells the story of Helen Keller, deaf and blind since infancy, who finds her way into the world of knowledge and understanding with the help of Annie Sullivan, her gifted tutor.

In some of the most turbulent and emotionpacked scenes ever presented on the stage, Helen overcomes rage and confusion to triumph over her physical disabilities.

The Miracle Worker is a story of vic-

New Moon, a 20 ft., interactive sculpture of light will illuminate downtown Lexington from Feb. 21 through the end of March as part of LUMINOSITY, an exhibition of light by the Lexington Art League (LAL).

Located in Triangle Park, New Moon is a magical experience that will delight families and downtown visitors of all ages. Viewers are invited to turn a large wheel at the base of the sculpture, which will rotate the sculpture, creating different phases of the moon.

Created by visiting Canadian artists Caitlind r.c. Brown and Wayne Garrett, and fabricated with the help of Bluegrass Community and Technical College students

in the BCTC welding shop, the sculpture is made of thousands of donated light bulbs that “fill out” the shape of the sculpture with LED lights creating a sparkling light show.

“The sculpture at Triangle Park will not be the kind of artwork that you passively admire,” says Stephanie Harris, LAL executive eirector. “Viewers will literally engage the work with their physical bodies, the effects of which will radiate throughout Lexington’s downtown cityscape.”

“At its heart, the entire scope of LUMINOSITY can be seen as a metaphor for how LAL wants to engage the community with visual art,” says Becky Alley, adding that the sculpture at Triangle Park embodies LAL’s Art for Everyone slogan.

More light-based artwork is also on view at The Loudoun House from Feb. 28-April 6, featuring photography, film, an interactive laser harp, and light-based sound installation by international and national artists. ◆

Luminosity an exhibition of light

Lexington

art league 32 M.D. UPDATE

Triangle Park: Feb. 21-Mar. 31 Loudoun House: Feb. 28-Apr. 6

World class care, close to home.

Our key partnerships include: • Appalachian Heart Center, the largest cardiology practice in Southeastern Kentucky, has joined the Gill Heart Institute office in Hazard, Harlan and Hyden.

• Patients in Louisville who need a heart transplant or ventricular assist device can have their initial evaluation closer to home through our partnership with Norton Healthcare.

Edward Setser, MD Cardiothoracic surgeon Director, Gill Heart Institute Hazard

• UK cardiologists see patients in Winchester in affiliation with Clark Regional Medical Center and in Georgetown in affiliation with Georgetown Community Hospital.

• UK cardiologists provide heart care at Rockcastle Regional Hospital in Mount Vernon and electrophysiology services at Ephraim McDowell Regional Medical Center in Danville and St. Claire Regional Medical Center in Morehead.

• We also offer access to the most experienced structural heart and valve team in the region for minimally invasive procedures, such as transcatheter aortic valve replacement, mitral valve repair and left atrial appendage occlusion.

Through our partnerships with communities across Kentucky, we are fulfilling the UK HealthCare mission to provide high-quality care to patients and their families close to home.

For more information or to refer a patient, call UK•MDs at 800-888-5533.

The art of heart care.

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