USC Health 2016 Issue 2 by USC Health by Keck Medicine of USC

A PUBLICATION OF KECK MEDICINE OF USC

VOL.  ISSUE 

™

1o Surgeons at USC Verdugo fight prostate cancer 18Hills 6 Pump Up the Volume robotic A surgery Big Win for Weight Loss with state-of-the-art

Sp ec i Ve al In r s Ho dug ert sp o H for ita ill U l s SC

Deep brain stimulation changes the life of a Parkinson’s disease patient

A PUBLICATION OF KECK MEDICINE OF USC

Keck Medicine of USC is the University of Southern California’s medical enterprise, one of only two university-owned academic medical centers in the Los Angeles area. Encompassing academic, research and clinical entities, it consists of the Keck School of Medicine of USC, one of the top medical schools in Southern California; the renowned USC Norris Comprehensive Cancer Center, one of the first comprehensive cancer centers established in the United States; the USC Care faculty practice; the Keck Medical Center of USC, which includes two acute care hospitals: 401-bed Keck Hospital of USC and 60-bed USC Norris Cancer Hospital; and USC Verdugo Hills Hospital, a 158-bed community hospital. It also includes outpatient facilities in Beverly Hills, downtown Los Angeles, La Cañada Flintridge, Pasadena, and the USC University Park campus. USC faculty physicians and Keck School of Medicine departments also have practices throughout Southern California.

Thomas Jackiewicz, MPH Senior Vice President and CEO for Keck Medicine of USC

Editor

Amanda Busick

Editorial Advisor Jeana Rettig

Contributing Writers

Hope Hamashige, Jessica Ogilvie, Candace Pearson, Carrie St. Michel

Business and Distribution

Carol Sussman

Graphic Design Lime Twig Group

Printer

ColorGraphics

Photography

Ricardo Carrasco III, Neil Kremer, Van Urfalian

©2016 Keck Medicine of USC Permission to reprint articles is available upon request. No artwork may be reproduced without the artist’s consent. Our mailing list comes from several sources. If you receive duplicate copies of this magazine, please send us all the label information and we will strive to eliminate the duplication. Direct inquiries to Keck Medicine of USC Marketing and Communications, SST-2830, 2011 N. Soto St., Los Angeles, CA 90032.

ON THE COVER 2 On Steady Ground

One patient seeks a return to stability through deep brain stimulation.

FEATURES 6 Pump Up the Volume A USC professor finds a way to be heard again at the USC Voice Center. 13 Early Adopter A Keck Medicine patient becomes first in the U.S. to have innovative new prostate cancer treatment.

14 Getting to the Heart of the Matter

Newly approved device helps one man with atrial fibrillation get back to his life.

16 Return to Form

This retiree’s spine surgeries spanned the spectrum—from the most complex to the most common.

18 A Big Win for Weight Loss

Keck Medicine of USC helps one man get on the right track with bariatric surgery to enable more successful weight management.

20 Healthoughts: Medical News You Can Use

HPV vaccination urged for young people, risk factors of esophageal cancer, health care tips via text—and more.

NEWS FROM USC VERDUGO HILLS HOSPITAL 9 Letter to the Community Letter to community from Keith Hobbs, new CEO of USC-VHH. 10 High-tech, Close to Home Surgeons at USC Verdugo Hills Hospital call on the latest surgical advances to tackle prostate cancer.

12 Safe and Sound A couple returns to USC-VHH for their third pregnancy, which may have complications to overcome.

KeckMedicine.org

COVER STORY

ON ON One patient seeks a return to stability through deep brain stimulation at Keck Medicine of USC. by Amanda Busick On a rushed morning one year ago, Mary Shea stood at a skycap booth at Reagan National Airport and struggled to remove her drivers’ license from her wallet. The skycap and people in line behind her impatiently waited as her hands shook trying to remove the license from the tight wallet pocket — an easy task if your fine motor skills are not compromised. For 10 years, Shea has lived with the physical effects of Parkinson’s disease (PD) and essential tremor (ET), a secondary movement disorder not related to PD.

Daniel Togasaki, MD, PhD, associate professor of neurology at Keck School of Medicine of USC.

“Subliminally, it’s always with you,” she says. “You might be at the happiest occasion, but always thinking about how your meds will work, what symptoms will be noticeable to others, and when your next dosage is due. Even when people know you, it is uncomfortable being on display in this way.”

DBS is a procedure that can decrease the tremors, dyskinesia (tics), and other movement issues that commonly come with Parkinson’s and ET and can often cut the amount of medication required. The majority of patients undergoing DBS have either PD or ET, meaning they will have only one area of the brain stimulated, typically on both sides. In Shea’s case, she had a double diagnosis of PD and ET resulting in two different areas of the brain requiring stimulation on both sides.

With the skycap’s help, she finally retrieved the license, but after the experience, she was more convinced than ever that she needed to take additional steps to improve her daily functioning and her life. It was time to pursue deep brain stimulation (DBS) with her neurologist, 2 (800) USC-CARE

WHAT IS DBS?

DBS is a series of two procedures in which electrodes are implanted in the brain while

These implanted devices use carefully programmed electrical impulses to reduce the physical symptoms of Parkinson’s disease and essential tremor. While most patients have either PD or ET and only one battery pack, Shea has been diagnosed with both diseases and has two implanted devices with wires on either side of her head. A DBS Leads—Thin insulated wires are inserted into the brain through small holes in the skull.

B Extension Wires—The wires are threaded under skin and down the side of the head and neck, and connected to the battery pack. C Battery Pack—This pacemaker-like device is implanted near the clavicle and sends pulses to targeted structures within the brain to help control tremors and other abnormal movements caused by the diseases in the body.

Shea was diagnosed with essential tremor in 2006, after noticing a tremor in her left index finger when it rested on the steering wheel of her car. Her neurologist at the time told her not to worry about it, but she did worry. Eventually, she sought out a movement disorder specialist. Enter Togasaki, who diagnosed her with both Parkinson’s disease and essential tremor in 2009. the patient is awake, though mildly sedated. Once the electrodes are positioned in the correct locations of the brain for the patient, wires are attached and coiled under the scalp for the second part of the operation, which typically occurs within the next one to two weeks. In the second procedure, the wires coiled under the scalp are unwound and channeled internally behind the ears, down the neck to the battery pack(s) implanted in this same operation in the upper chest. The battery pack, somewhat similar to a pacemaker, sends electrical impulses that stimulate specific areas of the brain, blocking abnormal electrical signals from targeted areas.

Shea says with a wry smile, “You don’t want to have your transmission worked on at an oil change place. Dr. Togasaki is my transmission specialist.”

A COORDINATED TEAM EFFORT DBS treatment at Keck Medicine of USC is a comprehensive, intensive process. A neuropsychologist, psychologist, a neurosurgeon and a social worker in some cases see patients with a definitive Parkinson’s diagnosis who are currently getting some benefit from the Parkinson’s medications. Patients are also encouraged to attend a DBS support group,

held at Keck Hospital of USC and run by Nasrin Esnaashari, NP, MSN, instructor of clinical neurology at the Keck School, who programs the DBS for each patient in a series of appointments after their second surgical procedure. Importantly, all specialists involved in the evaluation process must reach a consensus that the patient is a good candidate for the DBS procedure. The group works closely together, meeting monthly to discuss the treatment of each patient on their roster. “Treatment for DBS involves many caregivers,” says Esnaashari, “But especially the neurosurgeon, the neurologist, and the nurse practitioner. Proper care can’t occur without all three sides of the triangle.” In addition to Togasaki and Esnaashari, Shea’s team includes renowned neurosurgeon Mark Liker, MD, assistant clinical professor of neurosurgery at the Keck School, who says this collaborative effort between specialists is important to the patient experience. KeckMedicine.org

Nurse Practitioner Nasrin Esnaashari works with Shea at a programming session after her surgeries.

“Fifty percent of the people who can benefit from DBS never consider the opportunity.” “We want good outcomes,” says Liker, who has 15 years experience performing DBS surgery at Keck Hospital. “We don’t want a lot of patients who are implanted to not receive benefit from the procedure. I can say almost universally every patient that’s cleared for surgery has a dramatic benefit from the DBS.”

VARIED SYMPTOMS AND CONSEQUENCES Part of the reason for this collaborative effort is the nature of Parkinson’s. “It’s a boutique disease,” Shea says. “Everyone is affected differently.” Many patients experience “freezing,” where their lower body refuses to move from a tile ﬂoor to a carpeted ﬂoor, for example. Some patients experience rigidity and/or slowness. 4 (800) USC-CARE

Some experience dystonia, painful muscle contractions in various body parts, such as the foot and ankle. Others experience tremors, fatigue, decline in fine motor skills, more general gait issues, balance problems and falls, a loss of sense of smell, trouble sleeping, diﬃculty speaking, or loss of the ability to use facial expressions. The symptoms and consequences are so varied, the disease can be diﬃcult to diagnose. Even with a proper diagnosis, some patients are not aware that they may be eligible for the DBS procedure. “Fifty percent of the people who can benefit from DBS never consider the opportunity,” says Esnaashari. Lack of access or fear of brain surgery could contribute to this low number. However,

the doctors that perform this surgery consider it minimally invasive, and most patients who undergo the procedures recover quickly afterwards.

really take the time to prepare you for the procedure in every way.”

Before surgery, patients are cautioned that DBS is not a cure, and it should not be expected to relieve all physical symptoms. However, many patients who receive this treatment report improvement in so many areas that they may feel as though they have a new lease on life.

The process continues to be comprehensive after the surgery. Some institutions program the DBS implants while the patient is under anesthesia for implantation of the battery pack, but this leaves the patient unable to respond to stimulus. At Keck Medicine, each DBS patient’s implants are programmed post-surgery, enabling the patient to be active and reactive to the changes. The programming is based on the patient’s clinical symptoms and its therapeutic effects occur when the contacts located in the brain are stimulated. There are patients still receiving benefit from their DBS device twelve years after their initial surgery, with only an occasional oﬃce visit for a check up and to do minor adjustments to the programming.

The benefits of this thoughtful and dedicated process are not lost on patients like Shea. “I can’t speak highly enough of Dr. Togasaki, Nasrin and the specialists of Keck Hospital,” she says. “As far as being cutting-edge, taking time with patients, explaining things to you, giving you hope for the future, they

“You don’t want to have your transmission worked on at an oil change place. Dr. Togasaki is my transmission specialist.”

CONTINUED COMPREHENSIVE CARE

Even before her DBS surgeries, Shea was very active in the Parkinson’s community. She spends some of her time lobbying for research funding and educational outreach. Now that her initial programming sessions are complete, she plans to continue to champion the advancement of research, patient education, and public awareness of Parkinson’s. With the progress she’s made thanks to DBS, her ability to do advocate and perform the normal tasks of everyday life are greatly enhanced.

ADVANCING PARKINSON’S DISEASE RESEARCH Researchers at Keck Medicine of USC are looking for volunteers with Parkinson’s disease and memory or thinking issues to discover if exercise and socializing can improve mild cognitive impairment (MCI) and executive function (EF). Recent studies in healthy aging show that skill-based exercise has an impact on MCI and EF. This important finding could mean that exercise will be able to arrest or reverse the effects of MCI and EF impairment in Parkinson’s patients. Principle investigator Giselle M. Petzinger, MD, assistant professor of neurology, is a movement disorders specialist at the Keck School of Medicine of USC. Her research focuses on clinical trials that examine the potential effects of lifestyle in modifying disease in order to find novel therapeutic targets for Parkinson’s disease. The study involves memory and cognitive evaluations, fitness evaluations, and a Parkinson’s disease assessment.

For more information, please call: (800) USC-CARE or visit clinicaltrials.keckmedicine.org/ clinicaltrials/408

With a steady hand and a smile on her face, Shea says, “It’s such a terrible disease, and to have this procedure available is like magic.”

ABOUT PARKINSON’S DISEASE* THEDOC

DANIEL TOGASAKI, MD, PhD associate professor of neurology at the Keck School of Medicine of USC

MARK LIKER, MD assistant clinical professor of neurosurgery at the Keck School of Medicine of USC

THEDOC

PD is the second most common neurodegenerative disease after Alzheimer’s disease.

1MIL

Approximately 1 million Americans have PD. There are as many as 60,000 new cases diagnosed every year.

Incidence of PD increases with age. Only 4% of people with Parkinson’s are diagnosed before the age of 50.

1.5

Men are one and a half times more likely to have PD than women. * Statistics from the Parkinson’s Disease Foundation

KeckMedicine.org

JUST AS VISION AND HEARING CHANGE OVER TIME, AGING CAN ALSO LEAD TO CHANGES IN THE LARYNX THAT CAN CAUSE A DECREASE IN VOICE VOLUME OR A CHANGE IN PITCH OR TONE. AND, WHILE A CHANGE IN VOICE IS NOT A LIFE-THREATENING CONDITION, IT CAN ALTER THE WAY A PERSON GOES THROUGH LIFE OR IS PERCEIVED IN THE WORLD. SPEAKING TOO QUIETLY CAN AFFECT HOW OFTEN AND WHERE THEY SOCIALIZE WITH FRIENDS AND FAMILY. IT CAN ALSO INTERFERE WITH A PERSONâ&#x20AC;&#x2122;S ABILITY TO WORK IF VERBAL COMMUNICATION IS A CRITICAL PART OF THEIR JOB.

by Hope Hamashige

6 (800) USC-CARE

“Going out with friends, trying to talk at family gatherings, had become problematic.”

Jed Dannenbaum never had one of those big, booming voices that would fill a room. The historian and documentary filmmaker says he was always on the soft-spoken end of the vocal spectrum but, in recent years, it was becoming harder to speak above a whisper. “Going out with friends, trying to talk at family gatherings, had become problematic,” says Dannenbaum, PhD, who is also a professor in the USC School of Cinematic Arts. Trying to make himself heard was increasingly difficult and often left his voice tired and raw.

When his wife started having trouble hearing him even in the quiet of their home, he decided to seek help from the USC Voice Center at the USC Tina and Rich Caruso Department of Otolaryngology–Head and Neck Surgery. Recent changes in technology have given new power to laryngologists who specialize in problems with the voice. New, high resolution endoscopes allow doctors to view slow motion images of the vocal cords in action. “For the first time we can actually see what they are doing and spot subtle abnormalities that we couldn’t before,”

says Michael Johns III, MD, director of the USC Voice Center and professor of clinical otolaryngology–head and neck surgery at the Keck School of Medicine of USC.

“ For the first time we can actually see what they are doing and spot subtle abnormalities that we couldn’t before.”

THEDOC MICHAEL JOHNS III, MD, director of the USC Voice Center KeckMedicine.org

THEDOC

LINDSAY REDER, MD assistant professor of clinical otolaryngology–head and neck surgery at the Keck School of Medicine of USC

THREE WAYS TO RAISE THE VOLUME Using one of these endoscopes, Lindsay Reder, MD, assistant professor of clinical otolaryngology– head and neck surgery at the Keck School, was able to watch Dannenbaum’s vocal cords in action while he spoke. She was also able to determine that his vocal cords no longer meet in the middle when he speaks, which is a fairly common byproduct of aging, and can cause decreased volume. Like many patients, Dannenbaum initially opted to try voice therapy and only began exploring other options when that failed to bring back significant volume. The USC Voice Center is the only integrated practice of laryngologists and speech pathologists specializing in voice in Southern California, offering patients like Dannenbaum seamless care.

1 VOICE THERAPY The first line of treatment for anyone suffering unwanted effects of an aging voice is voice therapy. Edie Hapner, PhD, professor of clinical otolaryngology head and neck surgery at the Keck School, says that many people experiencing trouble with an aging voice mistakenly think they need to rest their vocal cords. Just the opposite is true. Just as muscles that have atrophied need strengthening, the muscles in the larynx also benefit from a rigorous workout. Hapner says most patients will require four to six sessions with a speech pathologist, who assigns them a series of progressively more difficult voice exercises, to make a major change.

2 IMPLANTS Some patients may need an implant to keep the folds of the vocal cords together. This solution is the most permanent, but requires surgery. Surgeons make an incision in the patient’s throat to insert a device that holds the folds around the vocal cords together. The patient is kept awake and can speak, which allows the doctors to make sure the device is serving its purpose.

3 FILLERS Fillers that are better-known for smoothing out wrinkles can also be injected to plump up the layers of vocal folds that thin over time. This outpatient procedure takes only a few minutes and a local anesthetic. Depending on the patient, the ﬁller may last for a few months or as long as a year before the procedure needs to be repeated.

Dannenbaum says Reder discussed the various options to help raise the volume of an aging voice (see sidebar). “She spent a lot of time talking me through it and explaining things in detail,” says Dannenbaum. Dannenbaum chose to have fillers injected into the folds of his vocal cords. Using many of the same fillers that are used to plump up wrinkled skin, such as hyaluronic acid or micronized acellular dermis, to bulk up a patient’s vocal folds is a relatively new treatment. Though not a permanent solution, Dannenbaum said the idea of an outpatient procedure that involved only a local anesthetic and less than a half hour of his time appealed to him. Only a few days after his procedure, Dannenbaum’s voice was already stronger and he’s looking forward to testing the strength of his newly pumped up voice in the classroom and at gatherings of friends and family. 8 (800) USC-CARE

Learn more at: ent.keckmedicine.org

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Dear Reader,

Letter to the COMMUNITY from Keith Hobbs

CEO, USC Verdugo Hills Hospital

It gives me great pleasure to introduce myself as the new CEO of USC Verdugo Hills Hospital. I am very happy to serve this community, and I am humbled by the responsibility I have to continue to grow our service quality, safety and patient satisfaction.

My ties to this community and to USC-VHH are numerous and long-standing. I was born and raised in the area, and all three of my children were born at this hospital. In fact, on my first day as CEO, I ran into a nurse who was present when my youngest was born. My wife started as a volunteer at USC-VHH and went on to be an employee for 13 years. I am proud to be continuing this important relationship that I have been fortunate to build over the years by coming home. Since my arrival, many changes have come to fruition at USC-VHH.

• Our orthopaedic surgery team has expanded to include many new faculty members from the Keck School of Medicine of USC, facilitating the department’s very first joint replacement surgery in January. • In January, Keck School faculty members used the da Vinci® Surgical System Robot for the first time here, ushering in a new era of technological advancements that will help our surgical patients receive even more effective treatment with fewer potential complications and side effects. • Our new spine program began in May and Keck School faculty members provide expert, specialized care for patients with serious spinal issues. Because of our combination of community physicians and Keck School of Medicine faculty, we can implement significant growth strategies, providing access to advanced medical care while continuing the USC-VHH tradition of being a caring community hospital. Over the months and years to come, I pledge that USC-VHH will continue our mission of providing personalized, high-quality health care that meets the needs of our patient community. I look forward to making this important journey with you. Sincerely, Keith Hobbs, CEO USC Verdugo Hills Hospital

USCVHH.org

HIGH TECH, CLOSE TO HOME

SURGEONS AT USC VERDUGO HILLS HOSPITAL CALL ON THE LATEST SURGICAL ADVANCES TO TACKLE PROSTATE CANCER. by Candace Pearson

Robotic surgery is relatively new at USC Verdugo Hills, having debuted in January 2016, but the team and program are long-standing. The USC Institute of Urology is a pioneer in robotic prostatectomies — urologists at Keck Medical Center of USC perform more of the procedures than at any other hospital on the West Coast. For Larry Peru, having minimally invasive robotic surgery for prostate cancer close to home at USC Verdugo Hills Hospital (USC-VHH) was more than simply convenient, it was confidence-building. “The technology is state-of-the-art — pretty cool,” says Peru, who went home the day after his March 3 procedure.

10 (818) 790-7100

On site at Verdugo Hills Hospital are two highly experienced surgeons: Mike M. Nguyen, MD, MPH, associate professor of clinical urology, and Rene Sotelo, MD, professor of clinical urology at the Keck School of Medicine of USC. Backing them up is a team of expert surgical nurses. “By offering our patients today’s most advanced treatment options near where they

live, we can support their recovery and make our personalized care that much more personal,” says Nguyen, director of robotic surgery at USC-VHH. The USC-VHH team is utilizing a powerful tool: the da Vinci® Surgical System from Intuitive Surgical Inc. Among its cutting-edge features are three-dimensional, high-definition images, which enable the surgeon to see structures inside the body at a detail impossible with normal vision. Sitting before a high-tech console, the surgeon controls the surgical system throughout the prostatectomy. Robotic, wristed instruments mimic the surgeon’s every movement, bending and rotating with greater range and articulation than the human hand. “Having these capabilities enables us to be even more precise in removing the cancer and protecting healthy surrounding tissue,” says Nguyen.

Robotic surgery accounts for 90% of all prostate cancer procedures. “The capabilities of the da Vinci® system, while impressive, are only as effective as the surgeon driving the machine,” adds Inderbir Gill, MD, MCh, founding executive director of the USC Institute of Urology. “Patients at USC Verdugo Hills can rest assured that not only do they have access to the most sophisticated medical devices, but also the most sophisticated medical minds and the most skilled surgical hands.” The minimally invasive technique requires only a few incisions — each less than an inch in length. The results typically are less pain and blood loss, minimal scarring, shorter hospital stays and faster recovery than traditional “open” surgery methods. That’s been the story for Peru, who was diagnosed with prostate cancer and an enlarged prostate in October 2015. His cancer was deemed low-risk, so Peru initially opted for surveillance, one of the alternatives Nguyen outlined for him.

Then, in February, when Peru returned to USC Verdugo Hills for a checkup, he announced he was ready to have the surgery. A busy man with two jobs and a growing family — he and his wife, Yolanda, share four children, four granddaughters and two great-granddaughters, with another grandchild on the way — he was eager for the next phase of his life, post-cancer. His confidence was boosted by a friend’s successful experience with robotic surgery, which now accounts for 90% of all prostate cancer procedures. Plus, Peru’s comfort level was reinforced by being able to have the high-tech option near his Atwater Village home. “It made everything easier for my wife, Yolanda,” he says, “so the procedure was a win-win for me.”

“ The capabilities of the da Vinci® system, while impressive, are only as effective as the surgeon driving the machine.”

INDERBIR GILL, MD, founding executive director of the USC Institute of Urology

Robotic surgery is just one of a series of ongoing developments at USC-VHH, which include renovation of the emergency care department, a high priority for 2016. Other newly expanded services include computernavigated joint replacement surgery, breast cancer lymphedema procedures, vascularized lymph node transfers and integrated care with Keck stroke specialists. “Our aﬃliation with Keck Medicine enables us to treat patients in the Glendale and La Cañada area with the standard of care you would expect from a renowned academic medical center,” says Keith Hobbs, CEO at USC-VHH. Peru’s robotic surgery went smoothly — and brought the best possible news. The cancer was confined to his prostate and his lymph nodes were clear, so he didn’t need follow-up chemotherapy. Initially, he experienced some minor post-procedure discomfort (“as if I’d been doing sit-ups”) but no pain. With his recovery well under way, he’s currently looking forward a carefree summer. On the agenda: boating on the Colorado River and camping in Yosemite with his family.

THEDOC

MIKE M. NGUYEN, MD, MPH associate professor of clinical urology at the Keck School of Medicine of USC

Learn more at: USCVHH.org USCVHH.org

WHAT IS PLACENTA ACCRETA? Approximately one in 2,500 pregnancies experience Placenta Accreta, in which the placenta attaches more deeply than usual to the uterine wall. While the speciﬁc cause of placenta accreta is unknown, it can be related to previous cesarean deliveries. This conditions can cause dangerous complications during delivery, primarily that of severe hemorrhage during attempts to detach the placenta.

••• “I knew I was in great hands.”

& SOUND

Safe

by Amanda Busick

USC Verdugo Hills Hospital gives an expectant mother peace of mind. When Linda and Goris Kadkhodazadeh found out Linda was pregnant with their third child, they had little doubt that they would return to the doctors they trusted at USC Verdugo Hills Hospital. She had already undergone two cesarean deliveries at USC-VHH for her children Alexander and Christopher, and she knew that it was the right place to care for her through this pregnancy too. Because of excessive amniotic ﬂuid discovered in an early ultrasound, Linda was considered at high-risk for pregnancy complications. Physicians monitored the fetus’ heart twice a week to make sure it was not in stress. Linda

was worried, but also comfortable with the level of care she was receiving. “They were very patient to answer all of my questions and concerns, and took extra time to go through the possibilities,” Linda recalls. “If it were a different hospital, I would probably have gone crazy because of my situation. I knew I was in great hands.” Because of Linda’s high-risk status, doctors set a specific due date for delivery, again by cesarean. But four weeks prior to the delivery date, physicians diagnosed her with possible placenta accrete, a potentially life-threatening condition. For Linda, there was also a risk her uterus would need to be removed during delivery. Every scenario was discussed and safety measures were taken to be sure that both mother and baby would survive, should drastic measures prove necessary. A team of five doctors from USC-VHH and the Keck School of Medicine of USC consulted on the case and made sure that everyone was working closely together and ready for every possible outcome. When the day of Linda’s delivery arrived, the doctors involved worked together to have a delivery that was both safe for mother and baby. The cesarean delivery of Sophia, a healthy baby girl, was perfect and the doctors were able to detach the placenta without incident. “Afterward, the support I received from the hospital was great,” says Linda. “They were very cautious and very concerned, and visited me every day to make sure that I was able to safely go home. They didn’t let anything slip through the cracks.”

12 (818) 790-7100

DECEMBER 10, 2015

Brett Lindsay becomes the first person in the United States to receive high intensity focused ultrasound (HIFU).

TODAY Feeling 100% back to normal.

Early

by Amanda Busick

Newport Beach resident Brett Lindsay is no stranger to innovative technology. As vice-president of a company that designs, builds, and maintains natural gas fueling stations for commercial transportation, being on the cutting edge of modern science has become second nature to him. So when faced with the challenge of prostate cancer, he was intrigued by the possibility of a groundbreaking new treatment that was soon to be offered by Keck Medicine of USC called high intensity focused ultrasound (HIFU) by Inderbir Gill, MD, MCh, founding director of the USC Institute of Urology and his team. Lindsay was getting some routine blood work done when his primary care doctor noticed that his PSA levels had been rising for a period of 18 months, and she sent him to

a specialist. The specialist performed a needle biopsy, and when Lindsay got the results back, he consulted a doctor to get a second opinion. That doctor was Gill, who is also chairman and professor of the Catherine and Joseph Aresty Department of Urology at the Keck School of Medicine of USC, who thought Lindsay was an excellent candidate for the innovative procedure. “HIFU has been very recently approved by the FDA in the United States,” Gill explains. “This technology allows us to be able to target precisely and destroy prostate cancer in a noninvasive fashion. There is no cutting involved, no blood loss, and the recovery is very quick, yet the precision with which the cancer can be eliminated is astounding.” With a patient under general anesthetic, the procedure uses an ultrasound beam to eradicate

cancerous tissue without radiation so patients are able to recover with minimal side effects. The recovery time with HIFU is remarkably swift. Lindsay did not have to stay overnight in the hospital, and within three weeks he was able to resume his busy schedule. Although he did have about three months of tissue swelling, he was able return to work within days, and resumed his travel schedule within a month. Lindsay believes it was the right choice to go with a new type of procedure and to come to Keck Hospital. “I feel I am 100% back to normal,” he states confidently. “No one ever wants to hear the words ‘you have cancer,’ but I am sure that I made the right decision on my procedure selection, doctors, and USC as my health care provider.”

THEDOC

Learn more at: urology.keckmedicine. org/prostate-cancer/hifu/

INDERBIR GILL, MD, MCH, founding director of the USC Institute of Urology KeckMedicine.org

“The Watchman is the only device that has a large amount of prospective data that demonstrates its, at least, equivalency with oral anti-coagulants, so you can mitigate your risk of stroke and without being subjected to the risks of being on an anti-coagulant.” –RAHUL DOSHI, MD

Getting to the

HEART of the MATTER

by Jessica P. Ogilvie

INSIDE WARREN KNAPE’S LA HABRA HOME, THE WALLS ARE LINED WITH BOOKS. IN THE LIVING ROOM, A SHELVING UNIT OVERFLOWS WITH PAPERBACKS AND HARDCOVERS. STACKS OF WORK-RELATED READING MATERIAL SIT ON HIS DESK.

14 (800) USC-CARE

THEDOC RAHUL DOSHI, MD director of electrophysiology and associate professor of medicine at the Keck School of Medicine of USC

Knape, 87, lives with his wife Doris in this cozy, sleepy town. A voracious reader, he started a book club at his church after reading The Shack by William P. Young. “I was so impressed with the book that I wanted to share it with people,” he says. Every week, he meets up with a friend to discuss scientific readings. And at the same church, he launched a support and training group for unemployed parishioners. But Knape’s ongoing work in the community might not have been possible were it not for the care he received in November of 2015 at Keck Medical Center. That’s when Rahul Doshi, MD, director of electrophysiology and associate professor of medicine at the Keck School of Medicine of USC, outfitted Knape with a Watchman device. The device prevents stroke in patients who suffer from atrial fibrillation, which is an irregular heartbeat. It does so without the need for blood thinning medications, which — for people like Knape — can otherwise drastically increase their likelihood of bleeding, including in the brain. Knape first noticed a problem with his heart about 14 years ago. “It scared me to death,” he says. “I had to go to the hospital.” He was diagnosed with atrial fibrillation, a disease affecting nearly 2.7 million Americans. If left untreated, atrial fibrillation can cause blood clots in the heart that can go to the brain and cause a stroke. Knape was treated with blood thinners, and on subsequent visits to the hospital, was told simply to rest for several days. But according to Doshi, certain patients are not good candidates for blood thinners. Those include elderly people over the age of 75, or who have already suffered a brain bleed — both criteria that Knape met. “Oral anti-coagulants all involve a risk of bleeding — the most feared of which is intracranial hemorrhage, or bleeding in the brain,” says Doshi. Knape, he adds, was the perfect

example of someone who could benefit from the Watchman device. Approved by the FDA in 2015, the device is inserted and plugs the left atrial appendage via a catheter. The appendage is where blood clots in those patients with atrial fibrillation typically occur. By closing the area off, the patient is far less likely to suffer a stroke from atrial fibrillation without the need for long-term blood thinners. “Warren is exactly the patient in whom we know we need to decrease the risk of stroke, yet he suffered a bleed around the brain, so we would be very concerned about him being able to tolerate long-term blood thinners,” says Doshi. “The Watchman is the only device that has a large amount of prospective data that demonstrates at least equivalency compared to oral anticoagulants, so you can mitigate your risk of stroke and without being subjected to the risks of being on an anticoagulant.” Knape received a call from Doshi soon after the device was approved, and Knape liked what he heard.

The procedure took about one hour, and was minimally invasive. He went home the same day, and his recovery has been speedy. The device allowed him to come off a medication that caused digestive side effects, and side effects on his thyroid. “I just didn’t like it,” he says of the medication. “It made the heart beat regularly, but it effected the other functions of the body.” But more importantly, it allowed him to get back to life as usual. “I guess you can tell,” he says, gesturing to the work on his desk, the books next up on his reading list, and his wife in the other room, “that I’m pretty busy.”

Learn more at: cvti.keckmedicine.org KeckMedicine.org

FORM

RETURN TO

THIS RETIREE’S SPINE SURGERIES SPANNED THE SPECTRUM—FROM THE MOST COMPLEX TO THE MOST COMMON. by Carrie St. Michel

“I CAN STAND UP STRAIGHT, AND I CAN LOOK STRAIGHT AHEAD,” SAYS RICHARD GROSSMAN, DDS, WITH AN INFLECTION REFLECTING A DASH OF DISBELIEF MIXED WITH ABSOLUTE APPRECIATION. TURN THE CLOCK BACK TWO YEARS, AND THIS ENCINO RESIDENT WAS NEITHER UPBEAT NOR UPRIGHT. “I FELT IF I HAD TO CONTINUE LIVING LIKE THAT, IT WASN’T WORTH GOING ON,” RECALLS GROSSMAN, REFERRING TO THE FACT THAT HE WAS — LITERALLY — STUMBLING THROUGH LIFE.

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Although he had retired as a practicing orthodontist a decade earlier, Grossman was still teaching in a graduate-level dentistry program. “I would walk from the parking structure to my classroom, and I would bump into trees and people and light posts,” he explains. “I was so bent over that I couldn’t see where I was going, and it was painful to look up.” Years earlier, Grossman had undergone several surgeries for spinal stenosis — a narrowing of open spaces within the spine that puts pressure on the spinal cord and nerve roots. He also had surgery for a life-threatening spinal staph infection. The surgeries and staph took a toll, leaving Grossman with ﬂat back syndrome — a loss of the spine’s natural curvature, forcing sufferers to lean forward and inhibiting the ability to stand upright. Tired of navigating life hunched over, Grossman asked a physical medicine/rehabilitation physician what could be done. The doctor replied that while there is a potential surgical solution, it can be so complicated he needed to research who had the neurosurgical skills to do it. This research led to the USC Spine Center and Frank Acosta, Jr., MD, associate professor of neurosurgery at the Keck School of Medicine of USC.

“I COULD STAND UP STRAIGHT RIGHT AWAY” A renowned neurosurgeon, Acosta is widely recognized for his expertise in complex spine deformity, revision spinal reconstruction, failed back syndrome, and minimally invasive spine surgery. Acosta recalls meeting Grossman for the first time. “Just looking at the way he was bent over, it was clear there was a big problem with global spinal alignment.” This was an issue demanding what Acosta describes as, “a huge spinal reconstruction and fusion surgery that had to be staged over two days.” Day one of the October 2014 surgery was devoted to inserting stabilizing titanium screws starting at Grossman’s upper thoracic spine and continuing down to his pelvis. Day two involved attaching rods between the previously placed screws and performing a

“ THEY REMEMBER ME BEING BENT OVER FOR SO LONG, AND THEY CAN’T BELIEVE HOW GREAT I LOOK AND THE FACT THAT I’M STANDING STRAIGHT AND TALL.”

USC SPINE CENTER The USC Spine Center stands apart by: Giving patients access to a truly integrated team of standardsetting neurosurgeons and orthopedic surgeons who are highly skilled across the spinal spectrum — from minimally invasive procedures to complex reconstructions.

pedicle subtraction osteotomy, a procedure in which a wedge of bone is removed from the lumbar spine and then closed to recreate a lower-back arch.

Alleviating pain and restoring mobility through leading-edge surgical and non-surgical approaches.

A daunting surgery no doubt, but Acosta specializes in complex spinal deformities and, as he points out, “at the USC Spine Center, we have a whole team dedicated to high-risk spine procedures. These surgeries are intense, but seeing how much they improve people’s quality of life is gratifying.”

Providing comprehensive, coordinated care including diagnostic testing, physical medicine, pain management, physical therapy, and occupational therapy.

Grossman’s two-day surgery unquestionably improved the quality of his life. “I could stand up straight right away,” he says, “and I was amazed how rapidly the recovery team was able to get me moving. I was ready to accept just a small improvement, but this was such a great improvement. It was wonderful.”

FROM TWO DAYS TO TWO HOURS Given Grossman’s rave review, it’s not surprising that he turned to Acosta again in the spring of 2015 when degenerated cervical discs started causing neck and arm pain. This time, rather than undergoing the most complicated neurological procedure, Grossman had the most common. Called anterior cervical discectomy and fusion (ACDF), this roughly two-hour surgery entails removing problem discs and replacing them with bone grafts held in place by small metal plates and screws. “Diseased or herniated discs in the neck are common, and we have very good results with ACDF,” says Acosta. Grossman is more than pleased with his surgical outcomes and says people continue to be amazed. “They remember me being bent over for so long, and they can’t believe how great I look and the fact that I’m standing straight and tall.”

THEDOC FRANK ACOSTA ACOSTA, JR., MD associate professor of neurosurgery at the Keck School of Medicine of USC

GROSSMAN’S OCTOBER  SURGERY Day 1 • Inserted stabilizing titanium screws starting at Grossman’s upper thoracic spine and continuing down to his pelvis. Day 2 • Attached rods between the previously placed screws. • Performed a pedicle subtraction osteotomy, a procedure in which a wedge of bone is removed from the lumbar spine and then closed to recreate a lower-back arch.

Learn more at: spine.keckmedicine.org KeckMedicine.org

by Hope Hamashige

KECK MEDICINE OF USC HELPS ONE MAN GET ON THE RIGHT TRACK WITH BARIATRIC SURGERY TO ENABLE MORE SUCCESSFUL WEIGHT MANAGEMENT. SHANT KIYORK STRUGGLED WITH HIS WEIGHT FOR YEARS. HE DIETED, EXERCISED, LOST WEIGHT, AND INEVITABLY GAINED BACK WHAT HE LOST AND THEN SOME. FEARING THAT HIS OWN ATTEMPTS TO CONTROL HIS EVER-GREATER WEIGHT WERE FAILING, HE CHOSE TO HAVE LAPAROSCOPIC GASTRIC BANDING SURGERY, COMMONLY CALLED LAP-BAND SURGERY, IN 2006.

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The lap-band was appealing to Kiyork because it was a less invasive procedure than gastric bypass surgery. But it later proved to be ineffective as a weight loss tool because, much like his yo-yo dieting, he lost a little weight initially and later gained it back. He also began to suffer from abdominal pain and started to have bouts of vomiting, both of which can be side effects of the lap-band. By the time Kiyork moved his family to Southern California, his excess weight was also threatening to create problems for him at work. A machinist by trade, Kiyork was beginning to have severe joint pain and he was concerned his weight would soon interfere with his ability to earn a living. At this point, he turned to Keck Medicine of USC. Kiyork’s experience is not uncommon, explains Namir Katkhouda, MD, director of the USC Metabolic and Bariatric Surgery Program at Keck Medicine of USC and USC Verdugo Hills Hospital. “You have to understand that, 10 to 15 years after initial weight loss surgery, you may sometimes have to redo it,” says Katkhouda, who is also professor of surgery at the Keck School of Medicine of USC. “The lap-band was once popular, but has not withstood the test of time.” It was clear that Kiyork’s body was in need of a second operation. But, before he could move forward with his surgery, he was required to go through a number of steps to make sure his heart and his mind were also ready. Weight loss surgery is not a magic pill and requires the patient make lifestyles

changes after surgery to stay healthy and free of complications. All patients of the USC Metabolic and Bariatric Surgery Program must attend a seminar led by Katkhouda and his colleagues during which various surgeries available to bariatric patients and their side effects are discussed. They also get a chance at the seminar to hear from previous patients about their experiences with weight loss and revision surgery. In addition, patients must attend counseling sessions with a nutritionist and a psychiatrist to make sure the patient understands what is going to happen and assess whether they are prepared to deal with some of the long term lifestyles changes that come with surgery. The procedure that Katkhouda recommended for Kiyork was first removing the lap-band and then performing a sleeve gastrectomy. Sleeve gastrectomy surgery is relatively new and involves removing about two-thirds of the stomach, including the part that secretes ghrelin, a hormone that signals hunger. Revising a previous weight loss surgery, says Katkhouda, is a far more delicate and meticulous operation than initial weight loss surgeries. This type of revision can be tricky because the stomach tissue is often changed by the presence of the lap-band. Because of its difficulty, many doctors remove the band and, after a period of healing, perform the sleeve gastrectomy in a second surgery. Katkhouda, who has performed hundreds of these surgeries, can do both procedures in one surgery for nearly all of his patients. “This is one thing that is special about USC,” says Katkhouda. “We do revisions and in 90 percent it is done in one shot and they don’t have to have another surgery three months later.” Three months after his revision surgery, Kiyork believes his weight loss is progressing well. He is

Though relatively new, sleeve gastrectomy has been proven to help with both weight loss and the concomitant problems of obesity. Patients can expect to lose approximately 80 percent of their excess weight. Many of those with high blood pressure or diabetes will stop needing treatment for their weight-related ailments.

THEDOC

NAMIR KATKHOUDA, MD professor of surgery and director of the USC Metabolic and Bariatric Surgery Program at Keck Medicine of USC and USC Verdugo Hills Hospital

eating more often, five to six times a day, but smaller portions and has shed 55 of the 180 pounds he needed to lose. His joint pain is gone and he can go to work and get through the day without feeling a lot of discomfort. Though he expects it will take at least a year to get to his goal weight, he is so confident that he is going to reach it he that has already bought a celebratory Burberry sweater, a brand he has long admired and never been able to fit into. He plans to wear it next winter when he hits his mark. “It was a great experience and Dr. Katkhouda is a great doctor,” says Kiyork.

Learn more at: surgery.usc.edu/ uppergi-general/bariatric KeckMedicine.org

Healthoughts Some good things to know.

Keck Medicine of USC: # in Acoustic Neuroma Treatment

FACT

The doctors of the USC Acoustic Neuroma Center see more patients with this condition than any other academic medical center in the United States, according to a recent evaluation by the University Healthcare Consortium.

FACT New Clinical Trial Open for Adults at Risk for Memory Loss WHO’S ELIGIBLE? PEOPLE BETWEEN THE AGES OF

to  WITH NORMAL THINKING AND MEMORY FUNCTION, OR WITH CONCERNS ABOUT THEIR MEMORY AND WITH EVIDENCE OF AMYLOID PLAQUES ON PET BRAIN IMAGING

Researchers at Keck Medicine of USC are looking for individuals 65 to 85 years of age who may be concerned about or at risk for memory loss and Alzheimer’s disease. The Anti-Amyloid Treatment in Asymptomatic Alzheimer’s study (the A4 study) is investigating a new drug intervention, Solanezumab, that may reduce the impact of a protein known as beta-amyloid that can accumulate in the brain with aging and form plaques. Researchers will use amyloid PET imaging scans to determine if a potential participant has evidence of elevated amyloid plaque buildup and would qualify for the clinical trial.

Acoustic neuromas, a non-cancerous form of tumor that affects hearing and balance nerves of the inner ear, occurs at the rate of 1 to 2 cases per 100,000 people. It is diagnosed using hearing and imaging tests.

For more information, contact the USC Alzheimer Disease Research Center: Nadine Diaz, MSW > ndiaz@usc.edu > adrc.usc.edu/healthcare-clinical-trials

Expert Health Care Tips on Your Mobile Phone Stay connected with the health care professionals at Keck Medicine of USC. Sign up at: keckmedicine.org/get-expert-tips

> Receive text messages about what you can do to stay healthy and be proactive in your medical care.

> You’ll be sent an opt-in text, and no more than two messages a month. > Data rates may apply. Unsubscribe at any time. 20 (800) USC-CARE

Rick Friedman, MD, PhD, director of the USC Acoustic Neuroma Center

If you or someone you know has been diagnosed with an acoustic neuroma, consult the team of experts at Keck Medicine of USC. For more information, visit acousticneuroma. keckmedicine.org. keckmedicine.org

HPV Vaccination Urged for Young People USC Norris Comprehensive Cancer Center has joined 68 of the nation’s top cancer centers in a joint statement urging parents and physicians to vaccinate young people against Human Papillomavirus (HPV). “The HPV vaccination is a safe, effective way to prevent cancers that occur in both men and women,” said USC Norris Director Stephen Gruber, MD, PhD, MPH. “Because the recommended age for this vaccine is between 11-12 years old, parents should speak to their child’s pediatrician about taking this important health precaution.” Vaccination rates remain low across the U.S. Research identifies a number of barriers to overcome to improve vaccination rates, including a lack of strong recommendations from physicians and parents not understanding that this vaccine protects against several types of cancer, including cervical, anal, oropharyngeal (middle throat) and other genital cancers.

,  in  CASES OF CANCER ARE CAUSED EVERY YEAR IN THE U.S. BY HPV

(NEARLY 80 MILLION) PEOPLE IN THE UNITED STATES ARE INFECTED WITH HPV source: Centers for Disease Control and Prevention

ESOPHAGEAL CANCER Are you at risk? People at high risk for esophageal cancer should get regular screenings. Early detection can lead to more successful outcomes.

of cases aﬀect those younger than 55

  , to

New cases each year

Trouble Swallowing

times more common in men than in women



SYMPT OM

less than

FACTS:

KNOW YOUR RISK

Chest Pain Unexplained Weight Loss

Risk Factors:

> Reﬂux > Barrett’s Esophagus > Tobacco & Alcohol Use > Obesity

To learn more about the procedures and services featured here or to schedule an appointment

CALL (800) USC-CARE (800-872-2273)

KeckMedicine.org

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THE KECK EFFECT: MORE HAPPY TIMES Keck Medicine of USC attracts the world’s top researchers and physicians. As a result, patients get greater access to more experts, more treatment options and more innovative surgical therapies. That’s The Keck Effect — doing everything possible to help our patients get more out of life. With locations throughout Southern California, exceptional care is close to you. See how we’re redefining medicine.

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