Archive for the ‘Articles’ Category

Fostering Educational Collaboration in Neurology at UNMC

The Department of Neurological Sciences at University of Nebraska Medical Center/Nebraska Medicine (UNMC), offers highly specialized and individually customized Neurology Preceptorship programs in Parkinson’s, Huntington, Botulinum Toxin Chemo-denervation, Movement Disorders, Deep Brain Stimulation surgery and continuous Levodopa infusion pump therapy. Participation by international healthcare professionals in such program experiences help enhance their skills in specific sub-specialties.

UNMC has a proven track record in clinical services, medical education, biomedical research, and international outreach. Danish Bhatti MD, Director of UNMC says, “Our primary focus has always been to provide exceptional educational opportunities and extraordinary patient care at all levels. Our Neurology Preceptorship program is yet another example to fulfill a strong need of sub-specialty training exposure for practicing international Neurologists”.

UNMC’s one to three month’s Neurology Preceptorship programs are designed for fully-trained international neurologists in active practice, who are interested in advancing knowledge in cutting-edge technology and current guidelines/practices in their area(s) of interest.

“With rapid advancements in all Neurological sub-specialties, our Preceptorship programs enhance experiences in Movement Disorders, Stroke, Neuro-Critical Care, Epilepsy, Neuromuscular Medicine, Multiple Sclerosis, Neuro-Immunology, Inpatient Neurology (Neuro-Hospitalist) and other sub-specialties.” says Dr Bhatti. “Research is also a vital part of the department’s activities, including clinical and translational research for neurologic disorders such as Alzheimer’s, Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis, Parkinson’s, Peripheral Neuropathy and Stroke”.

Nizar Mamdani, executive director and founder of the International Healthcare Services says, “Dr. Bhatti is an inspiring and remarkable example of the caliber of specialists and researchers working tirelessly to help provide better Neurology treatment and educational opportunities. Through collaborative strategic partnerships with 122 institutions in 44 countries, we continue to provide innovative educational and treatment options, as well as specialized tele-pathology and second opinion consultation services for Neurology, Cancercare and Transplantation patients around the world,” says Mamdani. Contact: nmamdani@nebraskamed.com; www.unmc.edu/international; +1-402-559-3656.

Oxygen Under Pressure – a future adjunct option for refractory wounds

By Dr. Lon W. Keim

 

Imagine being at risk of losing one of your feet.

That’s what a mother of seven from Kuwait with advanced diabetes mellitus recently faced before coming to Nebraska Medicine and the University of Nebraska Medical Center, through the assistance of the Office of International Healthcare Services.

She presented with a problem wound involving her right foot, now threatened by potential amputation. Her management was further complicated by the need of dialysis three times per week for her end stage renal disease.

Years ago Dr. Jefferson Davis and Dr. Thomas Hunt coined the term “problem wounds,” which they defined as wounds which simply do not heal as they should.

Through their experience and research they determined that a common denominator of problem wounds is tissue hypoxia or oxygen deprivation. Tissue hypoxia is commonly a result of three factors: inadequate oxygen in the blood, insufficient regional blood flow, or most often – focal oxygen demand exceeds delivery. That is the metabolic demands of the wound exceed oxygen delivery from the available blood supply.

Accordingly, the body’s inherent defense mechanisms – the ability to fight infection, generate new blood vessels, build tissue, create strength, provide coverage – are forced to function in an oxygen deficient environment. Thus a problem wound, like the one the woman from Kuwait experienced, is created.

Re-establishment of local regional blood flow through vascular enhancement procedures such as arthrectomies, angioplasties, stent placement, and bypass procedures is the essential cornerstone of initial management.

Hyperbaric Oxygen Therapy (HBO) also has been found to be a useful adjunct in selected patients who tissue oxygenation is not improved to accepted levels by revascularization procedures The patient is entirely enclosed in a monoplace chamber  and breathes 100 percent oxygen at pressures greater than  1.0 atmospheric pressure absolute (ATA).

With increased pressure, the amount of oxygen physically dissolved in the blood is increased. This increased oxygen pressure in plasma enhances diffusion from existing vasculature and improves regional wound tissue oxygen tensions.

The increased oxygen tension will not make a normal wound heal faster, but allows an otherwise compromised wound to heal through improved white cell function, enhanced antibiotic effectiveness, promotion of micro-vessel growth and collagen formation. It should be emphasized that HBO is not a substitute for adequate debridement or appropriate antibiotics, adequate nutrition, or local wound care.

Prior to coming to Nebraska, the mother from Kuwait had been evaluated by clinicians in Europe who believed nothing further could be done with amputation being the next most likely course of action.  She was subsequently referred to Nebraska Medicine where vascular surgeons were able to improve her distal vascular circulation through angioplasties and stent placement.

Subsequent transcutaneous oxygen assessment confirmed marginal tissue oxygen tensions that reversed with Hyperbaric Oxygen Therapy, thereby justifying further treatment with HBO. While continuing her dialysis three times a week, through a series of HBO treatments at 2.4 ATA  for 90 minutes each, local wound care, and pressure off loading, her wound oxygen tensions improved, allowing her wound to heal to a degree it was believed she could be safely discharged and return to Kuwait with her limb intact.

It should be emphasized that her recovery was the result of a team effort that included: skilled surgeons, gifted interventional radiologists, talented infectious disease expertise, attentive nurses, ongoing dialysis support, pressure off loading, aggressive nutritional support, and hyperbaric oxygen therapy.

The Hyperbaric Unit at Nebraska Medicine is equipped with four monoplace chambers capable of treating patients at pressures up to 3.0 ATA. The unit is staffed by hyperbaric trained critical care nurses, and is located immediately adjacent to an ICU. As such, the Nebraska Medicine specialists are capable of both treating walk-in outpatients as well as those requiring intensive critical care support. Although available 24/7 for emergent conditions, the unit routinely runs four shifts a day, with the majority of patients treated once daily five days a week.

HBO is viewed as the primary treatment for only three conditions: (1) acute carbon monoxide intoxication, (2) decompression sickness (bends), and air emboli (air bubbles within the vascular system).

For all other conditions, HBO is viewed as adjunctive therapy to the traditionally accepted mandates of care: adequate debridement and wound care, pressure off loading, edema control, nutrition, wound care, appropriate antibiotics, etc.

The following conditions have been approved and are endorsed by the Undersea and Hyperbaric Medicine Society (UHMS) as appropriate for treatment with HBO: (1) Clostridial myonecrosis – gas gangrene, (2) Necrotizing Soft Tissue Infections, (3) Refractory Chronic Osteomyelitis, (4) Compromised Flaps & Grafts, (5) Diabetes Mellitus – with lower extremity problem wounds refractory to conventional management for > 30 days, Wagner III-IV, (6) Delayed Radiation Injury – to Soft Tissues and Bone including radiation cystitis, radiation caries, colorectal radiation enteritis, or any chronic non-resolving chronic wound within a prior area of radiation, (7) Crush Injury – Skeletal Muscle Compartment Syndromes, (8) Intracranial Abscess, (9) Idiopathic Sudden Sensorineural Hearing Loss, (10) Exceptional Blood Loss Anemia, and (11) Thermal Burns.

The risks and side effects associated with HBO therapy are few. They include: confinement anxiety; barotrauma to the ears sinuses and potentially the lungs; fire (controlled by rigid adherence to strict safety protocols), rare oxygen induced seizures; and occasional transient reversible changes in vision. All in all, it is extremely well tolerated with minimum risks.

Multiple Myeloma 2016: where do we stand?

Multiple myeloma (MM) is the second most common hematologic malignancy in the United States, with rising incidence and prevalence, and is fast becoming an expanding health care burden globally. At a median age of 69, it may manifest differently, however, detrimental effects of abnormal plasma cells invariably involve the bone marrow, skeleton, kidneys, electrolytes and may predispose patients to infections by impairing immunity.

Though considered incurable, the field of MM, the survival of patients has more than doubled over the past decade.

Muhamed Baljevic, M.D., a multiple myeloma specialist and his team at the University of Nebraska Medical Center/Nebraska Medicine (UNMC) have been providing the latest treatment option include the use of cornerstone agents such as proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs), and their combinations. Daratumumab and elotuzumab recently became the first monoclonal antibodies to join the therapeutic armamentarium against MM.

Unfortunately, despite tremendous advances and ever increasing degrees of response, disease usually relapses, with decreasing remission durations upon each additional treatment.

On the brighter side, small molecules and an array of antibodies against other surface antigens and immune checkpoints are already part of early phase development in humans. The present appears to suggest chemo-immuno approaches as the future standard in the front-line setting, for both transplant eligible and transplant unfit patients. Consolidation therapy with Bi-specific T-cell engagers (BiTE), vaccine and checkpoint immunologic approaches also promise to push the boundaries of short and long-term outcomes.

Nizar Mamdani, executive director of UNMC’s International Healthcare says, “Dr. Baljevic and his expert team are remarkable examples of the caliber of specialists and researchers working tirelessly to help provide better treatment options”.

“Through collaborative strategic partnerships with 124 institutions in 44 countries, we continue to provide innovative treatment options, as well as specialized tele-pathology and second opinion consultation services for cancer care, neurology and transplantation patients around the world.”

UNMC also provides no-cost, training and educational programs. “Through our customized training programs, we facilitate patients around the globe to be the ultimate beneficiaries of the most advanced treatment options and empower them to receive the latest treatments in their own home countries,” says Mamdani.

Cancer Diagnosis Changes One Nurse’s Outlook

The following blog is written by Diane Cox, staff nurse at the Peggy D. Cowdery Patient Care Center. She has spent years treating our patients, but recently the roles were reversed following a breast cancer diagnosis.

After being diagnosed with stage 1 breast cancer, Diane Cox changed her approach in caring for cancer patients.

After being diagnosed with stage 1 breast cancer, Diane Cox changed her approach in caring for cancer patients.

I started my nursing career at Nebraska Medicine in 1985 on the Med-Surg Unit, which is now the Oncology Hematology Special Care Unit (OHSCU). After working on the OHSCU for 20 years, I transferred to the Peggy D. Cowdery Patient Care Center. I love working in oncology because there are so many new advancements in cancer treatment. I have the opportunity to teach, be a patient advocate, work closely with the physicians – and even work with my daughter, who is also a nurse in the treatment center. I’m learning something new every day. But the biggest lesson I’ve learned (so far) came in the most unexpected way.

In November 2015, I was having a routine mammogram. The report showed a focal asymmetry that was followed up by an ultrasound. I was told it was most likely a cyst. As time went on, I continued to check the area and still felt dimpling and a lump. Towards the end of January, I contacted my midlevel in the Olson Center for Women’s Health. She was persistent and repeated the mammogram, followed by another ultrasound. Diagnostic radiologist Lucy Muinov, MD, discovered the tumor and did a biopsy. On Feb. 4, I got the gut-wrenching call that confirmed I had breast cancer. It was devastating, scary and an emotional rollercoaster. A cancer diagnosis really shakes your world and makes you wonder if you’ll see your kids and grandkids grow up.

The next step was to meet with my cancer team at the Multidisciplinary Breast Cancer Clinic at Village Pointe, which included medical oncologist Elizabeth Reed, MD, surgical oncologist Sarah Thayer, MD, and radiation oncologist Andrew Wahl, MD. They developed a plan. I cannot describe how professional, fantastic, reassuring and informative they all were. My surgery was March 10, which involved a lumpectomy and sentinel node biopsy. Thankfully, I was stage 1 with no nodes positive for cancer. After recovering from the lumpectomy, the plan called for radiation, followed by an estrogen-blocking drug that I have to take for the next five years. I had 21 radiation treatments and cannot say enough about our radiation oncology staff. They truly made a scary experience less apprehensive. The radiation caused some fatigue and skin breakdown, but overall was manageable. The lumpectomy itself was not as painful as the sentinel node biopsy, but after two weeks off I was back at work.

When I returned to the treatment center, I changed the way I approach nursing. I now know how important it is to be patient with cancer patients. Sometimes they’re angry or scared. Sometimes they just need to talk to someone other than a family member. On the outside, they may be trying to stay strong – but inside they’re an emotional wreck. I’ve developed lasting friendships and connections with patients and their families. My advice for others – keep the patient informed, assure them, teach them and really try to understand how this has turned their world upside down.

Becoming a patient is very humbling and adding cancer into the equation makes you feel so vulnerable. You have to trust the people caring for you. Throughout my entire treatment plan at Nebraska Medicine, I always felt safe in my care, had all my questions answered and knew I was in the best hands possible. My family of co-workers are the very best. I truly believe we have the most caring and supportive staff.

Being a breast cancer patient has really changed my focus on life. As the married mother of three grown children with five grandkids and another one on the way, I know how important it is to take care of myself. I no longer sweat the little things. Life is too short – take time to enjoy your family and friends. Most importantly, be your own advocate when it comes to your health – be persistent if you think there is a problem.

New Procedure a First for Nebraska

A neck injury sent Scott Winter to the ED, only to discover he suffered from atrial fibrillation. His cardiologist, Shane Tsai, MD, recommended a new procedure that would prevent his heart from beating irregularly. Winter would be the first patient in the state to undergo this procedure, performed by HelenMari Merritt, DO.

Watch more in this video below.

Less-invasive Option for Thyroid Surgery

Estelle Chang, MD.

Estelle Chang, MD.

It’s a new option for patients who require thyroid surgery, one that’s much less invasive. Minimally-invasive robotic surgery is now offered at Nebraska Medicine for patients who need thyroidectomy, meet specific criteria, and desire a procedure that won’t leave a visible neck scar.

Estelle Chang, MD, an Otolaryngology Head and Neck surgeon, recently returned from a six month Advanced Robotic Head and Neck Endocrine Surgery fellowship at Yonsei Severance Hospital in Seoul, South Korea.  During her fellowship training, Dr. Chang also studied the latest, minimally invasive, thyroid and parathyroid surgery techniques. She also offers minimally invasive robotic surgeries for patients who need to have their submandibular gland, thyroglossal duct cyst and other non-cancerous lesions from neck removed.

“Traditionally, thyroidectomy has been performed using a 4 to 8 cm incision in the front of the neck which leaves a very visible scar,” says Dr. Chang. “Robotic thyroidectomy is the latest, minimally invasive surgical technique that is used to remove all or part of a thyroid gland without leaving a visible scar.”

Robotic surgery for thyroid disorders in the United States is currently offered at a few leading academic medical centers. It is considered to be a very safe procedure in the hands of an experienced robotic surgeon, says Dr. Chang. Robotic surgery can also be used to remove other benign masses of the neck, such as lipomas and thyroglossal duct cysts.

Lauritzen Outpatient Center Latest Openings

Nebraska Medicine and UNMC opened level one last week and level three yesterday of the Laurtizen Outpatient Center. By shifting outpatient services from main campus as well as adding complimentary support services for one-stop, patient-centered care, we are creating a better patient experience. Dedicated surface and garage parking for patients and their families offers a new convenience not historically found on the main campus. So far, the staff and physicians are embracing the new delivery of care.

“Having our clinic, X-ray and Physical Therapy in close proximity has made for a much more efficient flow of our patients through our facility and has improved our patients’ experience dramatically,” says Matthew Mormino, MD, orthopaedic surgeon and professor of Orthopaedic Surgery at UNMC.  11-23-lauritzen-shared-work-space

Also, new to the format of Lauritzen Outpatient Center are shared work spaces for physicians and staff that lead into patient rooms

11-23-lauritzen-clinical-exam-room

 

Services on level one include:

  • Orthopaedics Clinic
  • Physical and Occupational Therapy (PT/OT)
  • Outpatient Pharmacy
  • Radiology
  • Laboratory Services

Services on level three include:

  • Ear, Nose & Throat and Audiology
  • Oral & Maxillofacial Surgery
  • Oral Facial Prosthetics
  • Surgery-Urology

Lauritzen Outpatient Center, including the Fritch Surgery Center, has been opening services over the course of the last three weeks and will be fully operational by Nov. 30. The schedule is as follows:

  • Level one: Orthopaedics Clinic, PT/OT, Outpatient Pharmacy, Radiology, Laboratory Services and Coffee Shop – NOW OPEN
  • Level three: clinics including Ear, Nose & Throat and Audiology, Oral & Maxillofacial Surgery, Oral Facial Prosthetics and Surgery-Urology – NOW OPEN
  • Level four: Orthopaedics faculty and research as well as Telemedicine opening throughout November
  • Level two (Fritch Surgery Center): Pre/post op and outpatient surgery – Opening Nov. 30
    Note: University Tower ORs are now permanently closed

New Development in Breast Cancer Surgery

 

Today, women diagnosed with breast cancer have multiple surgical options to choose from.

Today, women diagnosed with breast cancer have multiple surgical options to choose from.

Today, women diagnosed with breast cancer have multiple surgical options to choose from. Historically, breast cancer surgery has been limited to removing the entire breast (mastectomy), or removing the lump (tumor) and preserving the breast. This is known as a lumpectomy, or breast conserving surgery. Advances in surgical techniques, as well as the need for improved breast cancer care, have resulted in the development of oncoplastic breast surgery.

Jessica Maxwell, MD

Jessica Maxwell, MD

What is oncoplastic breast surgery?

Oncoplastic surgery combines traditional lumpectomy with plastic surgery techniques. Once the tumor has been removed, the breast is reshaped in order to provide the most visually pleasing outcome. Reshaping the breast prevents contour deformities and allows for better cosmetic results. Removal of the tumor and reshaping of the breast are done during the same operation.

Is it safe?

Oncoplastic surgery does not compromise your cancer care. Safe treatment of breast cancer is always our number one priority. The goal is to remove the tumor with clear margins, the same as in traditional lumpectomy operations. Radiation treatment is generally recommended following oncoplastic breast surgery, just as in standard breast conserving surgery. Studies comparing traditional breast conservation and oncoplastic surgery have shown comparable outcomes. Oncoplastic surgery is equally safe from a cancer perspective.

There is a difference when we compare cosmetic outcomes and quality of life. Women who undergo oncoplastic surgery are more satisfied with the cosmetic appearance of their breasts. This can lead to improved quality of life through better self-confidence, self-esteem, and comfort with intimacy.

Oncoplastic surgery combines traditional lumpectomy with plastic surgery techniques.

Oncoplastic surgery combines traditional lumpectomy with plastic surgery techniques.

What are the possible complications?

As with traditional lumpectomy, complications are possible. These may include bleeding, infection, changes in breast and nipple sensation, wound healing issues, asymmetry, cosmetic dissatisfaction, and need for reoperation.

On occasion, a second operation is needed to treat the cancer. This may happen if the first surgery failed to remove all of the disease. This can happen in any breast cancer surgery, but can be challenging in oncoplastic surgery because the tissue has been rearranged. A larger surgery may be needed to remove the remaining cancer. This may include mastectomy. To avoid this, imaging studies such as mammogram, ultrasound, or MRI may be done before your surgery to fully assess the location and extent of the disease.

What about the opposite breast?

Oncoplastic surgery generally results in a smaller, rounder breast on the operative side. Radiation can further shrink or tighten the breast. To achieve symmetry, the opposite breast can be reshaped or reduced. Surgery on the opposite breast can be done at the time of the cancer surgery, or later on, once all of the breast cancer treatment has been completed.

Which patients are good candidates for oncoplastic breast surgery?

Oncoplastic surgery is ideal for women with moderate to large sized breasts who require a large volume of breast tissue removed. By reducing and reshaping the breasts, some symptoms of macromastia (large, heavy breasts) may be reduced. These include back, neck and shoulder pain, and recurrent rashes under the breast. Most women who have had previous breast surgery are still candidates for oncoplastic surgery.

Women with very small breasts and those who smoke heavily are not ideal candidates for oncoplastic surgery. Oncoplastic surgery is not recommended for women who require mastectomy to safely remove the entire tumor, or for women unable to undergo radiation treatment. Your breast surgeon can help determine if this approach is right for you.

Nebraska Medicine now offers oncoplastic surgery to appropriate candidates.

Nebraska Medicine now offers oncoplastic surgery to appropriate candidates.

What are my breast surgery options at Nebraska Medicine?

Nebraska Medicine now offers oncoplastic surgery to appropriate candidates, along with multiple other breast cancer surgery and reconstruction options. Remember – treating breast cancer is our main concern. You, along with your breast oncology team, will decide which option works best for you.

Dr. Vetro aims to improve treatment for cancer patients

Image with caption: Joseph Vetro, Ph.D.

Joseph Vetro, Ph.D.

Joseph Vetro, Ph.D., assistant professor of pharmaceutical sciences, wants his research to impact patients. Publication is great, yes. But what does it mean if it doesn’t eventually help people?

And Dr. Vetro believes that technology to effectively deliver RNA interference molecules (RNAi) can improve treatment for cancer patients. RNAi could be used to suppress gene expression in tumors that causes them to eventually become more resistant to chemotherapy. This could make chemotherapy more effective for people fighting cancer.

The tough part is getting therapeutic levels of RNAi into cancer tumors and metastases. Administered intravenously, RNAi levels end up undetectable, ineffectual.

Dr. Vetro had an idea to increase the potency of RNAi in tumors by forming polymer complexes with cholesterol-modified RNAi. He has preliminary evidence that this works.

But the stuff he’s working on in his lab needs to traverse many steps to get to clinical translation, to people. How does one do this? He needs someone else, a big company, to pick it up and take it the rest of the way, to the marketplace. And to do that? He needs to de-risk it, so it’s a good investment for these companies, by obtaining favorable Phase I clinical trial data. That makes it a better sell.

“You need to get industry to take a serious look at you,” Dr. Vetro said.

To start the process, Dr. Vetro and his wife formed a startup company, Actorius Pharmaceuticals, which recently was awarded National Institutes of Health (NIH) Small Business Technology Transfer (STTR) grant with UNMC collaborators Rakesh Singh, Ph.D.; Samuel Cohen, M.D., Ph.D.; Yazen Alnouti, Ph.D.; and Kenneth Cowan, M.D., Ph.D. They’re working to move the technology closer to a Phase I clinical trial in breast cancer patients.

To attract a company, they’re thinking like a company. They are working with a strategic business consultant and have obtained matching economic development funding from the state.

The ultimate end goal is to develop the technology for clinical use. How? “Sub-license the technology to a pharmaceutical company,” Dr. Vetro said.

It’s a strange thing to put so much work into something, to discover it, to nurture it, to have it be yours, only to give it away.

But isn’t that what we do?

“It’s like letting your kids go out into the world,” Dr. Vetro said.

It would be a big day to see the kids all grown up.

 

18 Years and Counting, Nebraska Medicine Wins Consumer Choice Award

11-14-consumer-choice-shieldIt’s once again evident folks in our region choose Nebraska Medicine over our competitors. For the 18th year, we’ve been awarded the National Research Corporation’s Consumer Choice Award, given annually to hospitals across the U.S. that health care consumers choose as having the highest quality and image.

The results for the 2016/2017 edition of the award were determined by consumer perceptions on multiple quality and image ratings collected from the company’s Market Insights Survey, the largest online consumer health care survey in the country. National Research surveys more than 300,000 households in the contiguous 48 states and the District of Columbia. The award is based on the hospital that possesses:

  1. Best overall quality
  2. Best overall image/reputation
  3. Best doctors
  4. Best nurses

“This award reflects the tradition of quality care at Nebraska Medicine,” says Dan DeBehnke, MD, MBA, CEO of Nebraska Medicine. “We will continue our quest for improvement, earning the confidence and trust of our patients and the communities we serve.”

Loading