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Archive for July, 2017

Effective Parkinson’s Management Requires Comprehensive Care by Multidisciplinary Team

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Danish Bhatti, MD

The needs of Parkinson’s patients are very diverse and become even more complex as the disease progresses.

“If we can get to them early on, we can initiate changes that are so important in making meaningful impact,” says Danish Bhatti, MD, neurologist and co-director of the Parkinson’s Disease Clinic at Nebraska Medicine, along with John Bertoni, MD, PhD.

The Parkinson’s Disease Clinic is a multidisciplinary clinic designed to provide comprehensive care by a team of specialists trained and experienced in treating Parkinson’s patients including physical therapists, speech therapists, occupational therapists, nutritionists, social workers and case managers.

Parkinson’s disease is the second most common neurodegenerative disease after Alzheimer’s disease and usually occurs in individuals after age 60. The disease typically advances slowly and affects movement, muscle control and balance. People with Parkinson’s may develop a tremor, slow movement, loss of balance, stiffness of the limbs, speech problems and difficulty swallowing.

“When the disease reaches a moderate stage, the movement problems become more pronounced, medication benefits may become less predictable and non-motor symptoms begin to worsen, such as swallowing difficulty, low blood pressure, sleep problems, mood and memory issues,” notes Dr. Bhatti. “This disease really takes a comprehensive, multi-disciplinary team to handle. We are here to collaborate with a patient’s primary care doctor and be involved in a patient’s care as much or as little as needed.”

“Proper diagnosis is the first step to begin proper treatment,” says Dr. Bhatti. “Unfortunately, Parkinson’s disease is sometimes misdiagnosed. Approximately 70 percent of Parkinson’s patients have tremors, which can be confused with one of many different tremor disorders. Because the other 30 percent of patients may not have tremors severely or at all, the diagnosis is even more difficult for these patients.”

Most people with Parkinson’s can get significant control of their symptoms with medications and a combination of other therapies, including: occupational therapy, speech therapy, nutrition counseling, support groups and regular exercise.

Beginning a regular exercise program early in the disease process can provide significant benefits to Parkinson’s patients and is important to continue as the disease progresses, says Dr. Bhatti. “People who are independent after 10 years are the ones who were very physically active early in the disease,” he says. “The more active you are, the less likely you are to have severe symptoms.”

Nebraska Medicine offers several exercise programs taught by certified instructors that are geared specifically for Parkinson’s patients and are recognized nationally. These include PWR! Parkinson Wellness Recovery® and the Lee Silverman Voice Treatment (LSVT) BIG® therapy program. PWR! helps patients with Parkinson’s disease improve function and slows motor deterioration by retraining sensory, motor and cognitive functions through intensive exercise and patient empowerment.

The LSVT BIG therapy program is a speech treatment program for individuals with Parkinson’s and other neurological conditions that can help improve vocal loudness, intonation and voice quality. Recent research studies have documented the effectiveness of this therapy in improving common problems such as disordered articulation, diminished facial expression and impaired swallowing.

“While we don’t have a cure for Parkinson’s, we continue to make progress in treatment,” says Dr. Bhatti. “There are newer forms of symptomatic therapy and new delivery methods, which are dramatically improving the control of symptoms.”

Some of these treatments are aimed at previously untreatable symptoms, such as medication for low blood pressure and hallucinations designed specifically for Parkinson’s patients. In addition, traditional medications like levodopa, can now be delivered through a stomach tube with a pump to provide more continuous and even control of symptoms.

Nebraska Medicine also offers other very effective therapies for Parkinson’s disease including chemodenervation with botulinum toxin and deep brain stimulation surgery. Deep brain stimulation uses mild electric impulses to stimulate the brain and block the signals that cause Parkinson’s symptoms such as tremors. It involves implanting a wire in one of several areas of the brain.

“The device is like a pacemaker for the brain. We are the leading medical center in the whole region that performs this procedure and have had great results,” says Dr. Bhatti.

Nebraska Medicine is also involved in several groundbreaking studies that are intended to slow the progression of Parkinson’s disease. “I believe we are on the verge of finding such therapy,” says Dr. Bhatti. “We encourage patients to seize opportunities to participate in clinical trials.”

Nationwide, approximately 60,000 Americans are diagnosed with Parkinson’s disease each year. The incidence of Parkinson’s disease in Nebraska and across the Midwest is higher than most states. According to the Nebraska Parkinson’s Disease Registry, in 2014 alone, 576 new cases were registered with Parkinson’s disease at the average age of 73 years and more than 13,000 patients have been registered since data collection started.

While the cause of Parkinson’s is still unknown, there is evidence connecting the disease to genetics, lifestyle and environmental factors such as exposure to pesticide chemicals, and head trauma.

“Ultimately, our goal is to do everything possible to provide great care to Parkinson’s patients in a multidisciplinary model,” says Dr. Bhatti. “This is one in which primary care physicians, therapists and movement disorder neurologists are all on one team – fighting with the patient and standing by their side.”

One of the Largest Living-Donor Kidney Transplant Chains

Nine Donors and Nine Recipients Meet Face-to-face for the First Time

All 12 of the donors and recipients attended the June 8 press conference.

All 18 donors and recipients attended the June 8 press conference.

Fourteen weeks after being part of the largest internal living-donor kidney transplant chain in Nebraska history, 18 people from different cities, states and backgrounds met face-to-face for the first time. The week of Feb. 27, nine patients received kidneys at Nebraska Medicine — Nebraska Medical Center from nine living donors. Previously, the largest internal living-donor kidney transplant chain here was a three-way exchange in July 2016.

This 18-person chain marks one of the largest single center kidney transplant chains involving a pediatric recipient in the United States. It’s also one of the largest single center kidney transplant chains performed in the U.S. in which none of the recipients were on hemodialysis (where a machine filters the patient’s blood outside their body). A 52-year-old Omaha woman, who wanted to donate her kidney in memory of a friend, started the chain.

Arika Hoffman, MD, became emotional while discussing the rare event.

Arika Hoffman, MD, transplant surgeon, became emotional while discussing the rare event.

“Without her, this never would have happened,” explains Arika Hoffman, MD, transplant surgeon. “One selfless act of an anonymous donor impacted the lives of 18 people.”

That woman is Sue Venteicher, a wife, mother and grandmother, who worked as a phlebotomist at Nebraska Medicine in 1988, before making the switch to Children’s Hospital & Medical Center.

“We can always do something for somebody else. It’s not the things you have – it’s the things you do for other people. Donating my kidney has been a wonderful experience,” says Venteicher. “When I worked at Nebraska Medicine, I always thought, ‘I could give my kidney to somebody.’ But at the time, I was busy having babies, so the idea went on the back burner.”

After raising her seven children, the opportunity to donate a kidney presented itself. Michael Peters was a former patient that Venteicher cared for at Children’s. He received a heart transplant as an infant and now needed a kidney transplant. Venteicher was tested – but unfortunately, wasn’t a good match. Peters received a kidney from a different donor in the summer of 2016. Shortly after, the transplant failed and his health problems worsened. Peters died in January at the age of 20. One month later, Venteicher donated her kidney to an anonymous recipient at Nebraska Medicine in honor of Peters.

Once the transplant team knew Venteicher was willing to start a kidney transplant chain, the planning process began in October 2016 and took about five months. Patient names were matched and rearranged several times on a large board in the transplant offices. The transplant team referred to this board as the Board of Hope – as it gave people a chance to receive living-donor transplants that otherwise would not.

The woman who started the chain, Sue Venteicher, was presented a unique "Tree of Life" necklace by

The woman who started the chain, Sue Venteicher, was presented a unique “Tree of Life” necklace by transplant surgeon Alexander Maskin, MD.

A kidney chain is an approach to living-donor transplantation in which an anonymous donor comes forward to donate a kidney to someone they do not know, starting a chain of events where patients with incompatible donors swap kidneys for a compatible one. Kidney transplants from living donors last much longer and tend to do better postoperatively. If individuals are open to doing a chain, the transplant team actively looks for exchanges.

“We have an obligation to get as many people transplanted as possible – especially with the scarce resource of deceased kidney donors. Exchanges and chains are the way to do that,” explains Dr. Hoffman. “The most exciting part about this chain was that it included recipients who were very difficult to match.”

“Many hours were spent at the Board of Hope, plotting, planning and finding potential matches,” says Vicki Hunter, Kidney/Pancreas Transplant manager. “We had to make sure everyone was healthy enough to participate. If a single person dropped out, the entire chain would fall apart.”

The morning of Feb. 27, Venteicher walked into the Nebraska Medical Center to start the chain. Two transplants were performed each day on Feb. 27 and 28, March 1 and 2, with the final transplant happening on March 3. Transplant surgeon Alexander Maskin, MD, performed the donor surgeries (known as a donor nephrectomy) and Dr. Hoffman transplanted them into the recipients. The chain included five patients who had not yet started dialysis, four who had a difficult time finding a match, and one person who was transplanted off the wait list. None of the recipients knew who gave them a kidney – until now.

On June 8, the 18 people involved in the chain finally met.

“This is our labor of love,” says Hunter. “It wouldn’t be possible without the living donors putting complete trust in the transplant team and saying ‘yes’ to the option of a chain. The donors didn’t know who they would ultimately give a kidney to, but they knew the end result was their intended recipient being transplanted.”

6-12 Kidney Chain wide of presser

Nebraska Medicine – Nebraska Medical Center is home to one of the most reputable and well-known organ transplant programs in the country. Since 1970, the organization has performed more than 1,000 living-donor kidney transplants. Nebraska Medicine transplants more patients on peritoneal dialysis (where the lining of the abdomen filters blood inside the body) than any other program in the world. It also performs more deceased donor kidney transplants on individuals who are nearing – but not yet started on dialysis – than any other program in the country.

Each year, the number of patients needing kidney transplantation increases while the number of deceased donors has remained about the same. If you’d like more information about becoming a living kidney donor, visit www.nebraskamed.com/kidneydonor.

For more on the celebration, watch our video below.

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Bariatric Surgery: A Growing Solution for Obesity

Obesity is a national health issue in this country with more than one third of all U.S. adults considered to be overweight. Bariatric surgery has become a growing solution for obese individuals.

“For many obese individuals, surgery provides the most effective long-term solution for weight loss when other methods have failed,” says Vishal Kothari, MD, bariatric surgeon at Nebraska Medicine’s Bariatrics Center. The Bariatrics Center is the most comprehensive program in the region offering medical weight loss, placement of a weight loss balloon, bariatric surgery and a meal replacement plan all in one location. The program is designed and directed by physicians who are fellowship-trained in medical weight management and bariatric surgery and are supported by a multidisciplinary team of specialists.

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Vishal Kothari, MD

“Approximately 80 to 90 percent of our patients have kept their weight off after five years,” says Dr. Kothari. “On average, people can expect to lose 60 to 70 percent of excess body weight, which can be 100 pounds or more.” Like any weight loss plan, patients have to make lifestyle changes to make it work including exercise and adopting healthy eating habits.

“One of the key aspects of the program that makes it different from many others is that we take a holistic approach to our care and follow our patients for life,” says Dr. Kothari. “After surgery, we follow them closely for the first 18 months and then annually to help keep them healthy and motivated. We work closely with their primary care doctor to check weight and nutrition, recommend labs and address any issues such as nutritional deficits, medical issues and any excess weight gain so we can help our patients stay on track.”

We also understand that a successful transition to lifelong healthy living requires more than just losing the weight and may require the support of other specialists, notes Dr. Kothari. As a result, the Bariatrics Center also includes medical nutritionists, an exercise specialist and a clinical psychologist to support a patient’s medical, physical and mental health throughout the process.

In addition to weight loss and improved quality of life, there are other reasons a patient and his or her physician may want to think about weight loss surgery. “Increasing evidence shows that it can help reduce a person’s risk for a number of serious diseases like diabetes, heart disease, arthritis and cancer,” notes Dr. Kothari.

Depending on the type of surgery and the amount of weight loss, bariatric surgery has been shown to improve or resolve diabetes in 50 to 85 percent of patients; reduce sleep apnea by 90 percent; lower high blood pressure by 60 percent; decrease joint pain by 60 to 70 percent; and drop high cholesterol by 60 percent. Bariatric surgery patients also have been shown to live longer than their obese counterparts.

A person may be considered for surgery with a BMI over 35 with other obesity-related health conditions, or a BMI over 40 and has tried various weight loss plans with no results.

The most commonly performed bariatric surgeries at the Bariatric Center include laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy and laparoscopic roux-y-gastric bypass. All of the surgeries are performed laparoscopically, which means they involve making several small incisions that are closed with only a few stitches, resulting in fewer complications and a much quicker recovery time for patients.

The Bariatrics Center at Nebraska Medicine also offers a newer, noninvasive bariatric procedure that can be performed endoscopically and is an alternative to traditional bariatric surgery. Orbera® gastric balloon is a reversible, nonsurgical weight loss procedure providing obese patients with another option to achieve significant weight loss when regular methods of diet and exercise have not worked, and traditional bariatric surgery isn’t a fit for them, says Dr. Kothari. “The procedure is very safe, can be performed as an outpatient and requires minimal recovery time,” he says.

“The health and quality of life benefits these patients receive from bariatric surgery and other weight loss methods are tremendous,” says Dr. Kothari. “They are more mobile, feel better about themselves, have less depression and have better family, social and work lives.”

The Bariatrics Center at Nebraska Medicine is nationally accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a combined program of the American College of Surgeons (ACS) and American Society for Metabolic and Bariatric Surgery (ASMBS). The designation recognizes surgical programs with a demonstrated track record of favorable outcomes in bariatric surgery. Clinical research shows that the most experienced and comprehensive bariatric surgery programs have much lower rates of complication.

Nebraska Medicine Announces Availability of Breakthrough New Treatment for Patients with Peripheral Artery Disease

Nebraska Medicine is among the first in the United States to offer a new treatment recently cleared by the U.S. Food and Drug Administration (FDA) to provide relief for patients suffering from the painful symptoms of peripheral artery disease, or PAD – a condition caused by a build-up of plaque that blocks blood flow in the arteries of legs or feet.

The device, Avinger’s Pantheris™ lumivascular atherectomy system, is an innovative image-guided therapy that, for the first time ever, allows physicians to see and remove plaque simultaneously during atherectomy – a minimally invasive procedure that involves cutting plaque away from the artery and clearing it out to restore blood flow.

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Nebraska Medicine vascular surgeon David Vogel, MD,
is now able to see and remove plaque simultaneously.

Because the Pantheris device incorporates real-time optical coherence tomography (OCT) imaging on a therapeutic catheter – like having a small camera on the tip of the device – physicians are able to remove this plaque more precisely than ever before, with less risk of damage to the artery walls which can result in aggressive scarring that greatly increases the risk of restenosis, or re-narrowing of the artery. In the past, physicians have had to rely solely on X-ray as well as touch and feel to guide their tools while they try to treat complicated arterial disease.

For patients, this safe and more-precise treatment may potentially reduce the need for follow-up procedures and stents.

“Peripheral artery disease greatly impacts quality of life, with patients experiencing cramping, numbness, discoloration and pain,” said David Vogel, MD, a vascular surgeon at Nebraska Medicine. “The Pantheris technology is on the front lines. Nebraska Medicine is the only hospital in the region using it. We’re helping lead the way.”

Clinical results confirm that the technology is safe and effective: a 130-patient study showed a target lesion revascularization rate of just 8 percent, and not a single event of vessel perforation, clinically significant dissection or late aneurysm resulted from Pantheris. In addition, this radiation-free technology may help minimize radiation exposure to clinicians and patients by decreasing use of fluoroscopy.

Peripheral artery disease affects nearly 20 million adults in the U.S. and over 200 million people globally. PAD is caused by a build-up of plaque in the arteries that blocks blood flow to the legs and feet. Often dismissed as normal signs of aging, symptoms of PAD include painful cramping, numbness or discoloration in the legs or feet. PAD can become so severe and difficult to address with traditional treatments that patients and physicians often resort to undergoing invasive bypass surgeries, which can result in even higher health risks and lengthy, painful recoveries. In severe cases, patients often face amputation, the worst-case scenario associated with PAD.

Atherectomy is a minimally invasive treatment for PAD in which a catheter-based device is used to remove plaque from a blood vessel. Lumivascular technology utilized in the Pantheris system allows physicians, for the first time ever, to see from inside the artery during a directional atherectomy procedure by using an imaging modality called optical coherence tomography, or OCT. In the past, physicians have had to rely solely on X-ray as well as touch and feel to guide their tools while they try to treat complicated arterial disease. With the lumivascular approach, physicians can more accurately navigate their devices and treat PAD lesions, thanks to the OCT images they see from inside the artery.

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