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Fall/Winter 2014 WHAT’S INSIDE Congenital Heart Disease Specialists Develop Nonsurgical Technique to Correct Birth Defects in Premature Infants . . . . . . . . . . . . . . . 2 Minimally Invasive Procedure Designed to Treat Birth Defect and Lessen or Eliminate Need for Heart Surgery in Fragile Infants Preventing Shoulder and Elbow Injuries from Tennis and Golf . . . . . . . 3 Heart Monitoring with the Reveal LINQ Insertable Cardiac Monitoring System . . . . . . . . . . . . . . . . 5 FEATURED PHYSICIAN Mark Weidenbaum, M.D. Professor of Orthopedic Surgery, Columbia University Medical Center Lung Cancer Screening: The Benefits of Early Detection L ung cancer remains the leading cause of death in many countries and is the leading cause of cancer-related mortality worldwide. In fact, more people die from lung cancer than colon, breast, and prostate cancer combined. When detected at its earliest stages, there is a high likelihood for cure if surgically treated. Unfortunately, once lung cancer produces symptoms, such as cough, blood in the sputum, or chest pain, it is often already at an advanced stage with very few effective treatment options available. Lung screening looks to identify cancer at its earliest stage, affording people the option of the most effective treatment. As of December 2013, the United States Preventative Services Task Force (USPSTF), a group of independent primary care and preventative services experts commissioned by the US government to make Dr. Weidenbaum specializes in the surgical treatment of spinal disorders, deformities, and degenerative conditions. He is dedicated to delivering the best possible care for acute and chronic conditions, as evidenced by the fact that he has earned near-perfect reviews on all the leading physician-rating websites, such as Healthgrades, Vitals, and RateMDs.com. This level of satisfaction is difficult to achieve. surgical care for their spine turn to Dr. Weidenbaum at Columbia Orthopedics. Back pain affects 8 out of 10 people at some point during their lives and usually resolves without surgery. When non-operative treatments fail, patients seeking the best possible He performs a wide range of procedures on the neck, upper back, and lower back that include microsurgical as well as complex spinal reconstructions. Dr. Weidenbaum is recommendations on national preventative services, gave lung screening a grade B recommendation. The letter grades given are based upon evidence available for the potential screening benefits and harms. Those that are given a grade A or B represent services that are recommended to a certain population at risk where the benefits outweigh potential harms. Currently, heavy smokers aged 55 to 80 and former smokers in the same age group who have quit within the last 15 years are the population thought to most benefit from lung screening. Heavy smokers are defined as people who have smoked the equivalent of 30 pack years (Figure 1). Continued on page 6 Figure 1 an active researcher and educator with leadership positions in national and international spine surgery organizations. In 1977, he graduated summa cum laude in Chemistry as a University Scholar at the University of Connecticut and went on Continued on page 6 Congenital Heart Disease Specialists Develop Nonsurgical Technique to Correct Birth Defects in Premature Infants Minimally Invasive Procedure Designed to Treat Birth Defect and Lessen or Eliminate Need for Heart Surgery in Fragile Infants Los Angeles – July 28, 2014 – A new technique for repairing the most common cardiac birth defect in newborns, commonly referred to as “a hole in the heart,” has been used successfully to mend the condition in six premature infants without subjecting the tiny patients to open-heart surgery. The technique for repairing the condition, patent ductus arteriosus, also called PDA, was published online by the peer-reviewed medical journal Catheterization and Cardiovascular Interventions, the official journal of The Society for Cardiovascular Angiography and Interventions. The study, published in the journal’s July print edition, was developed by a team in the Cedars-Sinai Heart Institute's Guerin Family Congenital Heart Program led by Evan M. Zahn, M.D., an expert in congenital heart disease. Ask the Doctors 2 “Just a few short years ago, the only treatments available for these babies was an intravenous medication regimen or heart surgery,” said Zahn, co-director of the Heart Institute's Guerin Family Congenital Heart Program and a leader in the field of nonsurgical cardiac interventions for pediatric patients. “Yet many of these babies are so fragile that we needed additional treatment options to ensure that these children have a healthy future ahead of them.” Patent ductus arteriosus is a condition in which a blood vessel called the ductus arteriosus, which routes blood around the baby's lungs prior to birth, does not close naturally as it should within a couple of days after birth. The opening leads to abnormal blood flow and can cause symptoms ranging from fast breathing and difficult feeding to brain hemorrhage Q : Does radiation from X-rays or CAT scans cause cancer? A : The cancer risk associated with medical radiation is a hard question to answer. We know that there is no lower threshold that will eliminate risk, meaning that there is no amount of radiation that is considered without risk for cancer. It is also true that the greater the amount of radiation a person is exposed to, the higher the risk of cancer. However, this increased risk must be balanced with the potential harm of missing a more life-altering diagnosis by not having a medical examination. When performed appropriately, the risk associated with and death in premature infants. The study in Catheterization and Cardiovascular Interventions followed six severely premature infants who were born with patent ductus arteriosus when they were between 26 and 31 weeks gestation. The babies in the study were between 16 and 80 days old and weighed between 1.9 and 4.9 pounds. All the infants in the study had successful closure procedures and did not experience complications. Zahn and his team— including Alistair Phillips, M.D., co-director of the Guerin Family Congenital Heart Program, Ruchira Garg, M.D., and Charles F. Simmons, M.D., director of Cedars-Sinai's Pediatrics Department and Division of Neonatology and the Ruth and Harry Roman chair in Neonatology in Honor of Larry Baum— Continued on page 3 routine medical radiation is dramatically outweighed by its potential benefit. Radiation effects can be categorized into two main types, either stochastic (chance) or non-stochastic (deterministic). Stochastic effects are related to radiation dose, where an increased radiation dose increases the probability of an adverse outcome, such as induction of cancer. Deterministic effects are those such as skin burns or GI upset occurring with massive doses of radiation (anywhere from 10 to 100 times that a person would be exposed to from diagnostic medical radiation) where effects only occur after reaching a threshold dose. The major concern that is discussed then is: What is the risk of developing cancer? Preventing Shoulder and Elbow Injuries from Tennis and Golf S Cedars-Sinai Medical Center cedars-sinai.edu ummer is a great time to enjoy sports like golf and tennis. Unfortunately, many seasonal athletes experience shoulder and elbow injuries from overuse. Most upper extremity ailments from golf and tennis are forms of tendonitis. Tendons are the connective tissues that attach your muscles to your bones, forcing your bones to move and your joints to bend when your muscles contract. Overuse and repetitive stress can cause focal irritation and pain at tendon sites. Overuse and repetitive stress without proper warm-up or endurance training may lead to tendonitis. “Poor form,” or poor body mechanics, when serving in tennis or hitting a 9-iron can also lead to tendonitis. Muscle fatigue and diminished endurance can cause a lapse form and technique that can overload certain tendons as they insert on bones causing tendonitis. Tendonitis feels like nagging pain near the bony prominences of the elbow or over side of the shoulder. Elbow tendonitis From what we know today, calculating a risk of cancer from a specific radiation exposure is impossible. This is secondary to many factors. Firstly, most data that we have regarding the risk of cancer from radiation are based on very high exposures, such as that in atomic bomb survivors. We can say with certainty that at these high doses, radiation does cause cancer. This information, when extrapolated to the relatively minuscule amounts of radiation a person is exposed to from medical tests, leads us to believe that while there is still a tiny chance of developing cancer, the necessity of undergoing these tests outweighs any of these risks. To further complicate the estimations, some of our body parts, such as our reproductive organs, are more sensitive to radiation than others. Finally, there are many different environmental causes of cancer and it is not possible to determine if a specific trigger is associated with someone developing cancer. Clearly, in life-threatening situations, such as in a car crash, obtaining an X-ray or CAT scan to identify areas of injury outweighs any potential risks of cancer. This is contrasted with some who advocate whole body CAT scanning in an otherwise healthy person, where the extra radiation is likely more harmful. Therefore, medical diagnostic radiation (X-ray or CAT scan) should only be used when there is a medical question to be answered and the risk of radiation is clearly outweighed by the benefit of the developed a catheter-based technique that employed sophisticated imaging technologies fluoroscopy and echocardiography to guide the physicians through the delicate closure procedure. “The development of new minimally invasive techniques to treat babies with PDA is a major step forward,” said Eduardo Marbán, M.D., Ph.D., director of the Cedars-Sinai Heart Institute. “The tiny size of premature infants renders open-chest surgery exceedingly risky; Zahn and colleagues can now fix the problem with a catheter, at the bedside in the neonatal unit, without exposing the internal organs. Lives have been saved, and many others stand to benefit as this new technology is disseminated.” Health News | Fall/Winter Spring/Summer 2014 2014 may affect the medial or lateral aspects of the elbow, commonly referred to as “golfers elbow” and “tennis elbow,” respectively. Shoulder tendonitis frequently affects the rotator cuff, muscles that power your shoulder motions. Individuals with tendonitis often experience no specific injury besides overuse. A discrete feeling of a pop, crack, or tear with bruising on the arm is NOT tendonitis and may indicate a completely torn tendon or Continued on page 4 information obtained from the test. To complicate matters further, screening, which is diagnosing disease in otherwise healthy people, opens the door for irresponsible use of medical radiation and unnecessary risks. This underscores the importance of adherence to strict guidelines. For example, current recommendations for routine screening are limited to certain diseases and in certain high-risk populations, such as breast and lung cancer in welldefined age and risk profiles. Patients can refuse any of these tests and should feel comfortable discussing these risks and benefits with their physicians. Bradley B. Pua, M.D. 3 Charles M. Jobin, M.D. Assistant Professor of Clinical Orthopedic Surgery, Columbia University College of Physicians and Surgeons; Assistant Attending, NewYorkPresbyterian Dr. Jobin specializes in the operative and non-operative treatment of shoulder and elbow disorders in adults at Columbia Orthopedics. He is an expert in shoulder and elbow reconstruction, minimally invasive, and arthroscopic techniques. His particular clinical strengths include treatment of shoulder and elbow arthritis, joint replacement, rotator cuff disorders, shoulder instability, tendon and ligament injuries, and fractures. Dr. Jobin, an athlete himself, has cared for local sports teams and provided orthopedic coverage during tournaments. Ask the Doctors Q : How should I prepare for an exotic vacation? A : The most important thing to do is seek advice from a travel clinic, especially if 4 Preventing Shoulder and Elbow Injuries from Tennis and Golf Continued from page 3 ligament and you should seek orthopedic medical care. Chronic tendonitis is characterized by a dull but persistent soreness that feels worse when you first start to move, and then eases up as your muscles get warmer. Chronic tendonitis is difficult to alleviate quickly and may persist for several months. Selftreatment focuses on avoiding the inciting activities and stretching, three times daily, the muscles of the forearm and elbow for 5 to 10 minutes per session. Acute tendonitis causes a sharper persistent pain that may keep you from moving the joint; this pain usually goes away after a few hours or days with rest, ice, compressive wrapping, elevation, and over-the-counter anti-inflammatory medications. Prevention is the best way to avoid the disabling pain of tendonitis. Professional baseball players and other professional athletes have very specific shoulder and elbow injury prevention training programs to keep their joints healthy and ward off you are going to an unusual travel destination. If you are going to Europe, the risk of acquiring illnesses is similar to what you would face in the United States, but there are different risks associated with going to other areas of the world—Africa, South America, Asia—and the physicians in a travel clinic can advise what can be done to minimize those risks. There are illnesses such as Japanese encephalitis that you will see in several areas of Asia, Southeast Asia, and some areas of Australia, but not in Africa, South America, or anywhere else. A disease called yellow fever is present in certain areas of South America and certain areas of Sub-Saharan Africa. You don’t find it in any other areas of the world. A very effective vaccine for yellow fever is injury. Key elements of a prevention program include a thorough warm-up that gradually builds in intensity, stretching the upper extremity and torso after warm-up, muscle strengthening and agility exercises that focus on proper body mechanics and sport-specific activities. The program should end with has a gradual cool down period. A proper prevention program should be repeated three or more days per week for at least 20-30 minutes, and should start a few weeks or months prior to the beginning of the sporting season. A short daily prevention program is better than a once a week intense work out. If shoulder and elbow pains do not alleviate with rest or they persistently interfere with daily activities, it is time to visit your orthopedic doctor. Other troubling symptoms, such as muscle deformity, feeling a pop or snap with bruising, significant weakness, or having the joint come out of its socket, are indications that you should seek expert orthopedic care. Charles M. Jobin, M.D. available, but you can’t get it from your primary care doctor; it’s a live vaccine that requires special training to monitor side effects, so only approved clinics can provide the vaccine. People who are going to areas where yellow fever is endemic should seek medical advice from a travel clinic to get the vaccine or to decide whether or not it’s appropriate for them because of other health issues they may have or because the vaccine will not be helpful in the particular area they are planning to visit. Travelers should also make sure that their general overall health is stable. I certainly do not advise someone whose chronic condition is not under control to travel without at least seeing their primary care doctor and having contingency plans in case GLOBAL CONNECTION Heart Monitoring with the Reveal LINQ Insertable Cardiac Monitoring System C apturing the electrocardiogram (ECG) of patients who suffer with infrequent blackouts or palpitations was almost impossible until the invention of the implantable loop recorder. The original device, the Medtronic Reveal, was the size of a memory stick and required a surgical implant in a hospital catheterization lab, often requiring intravenous sedation and post-operative monitoring. Many patients were put off by the size of the device, especially women, who did not want a chest scar. The new Medtronic Reveal LINQ™ is the smallest heart monitor on the market—the size of two matchsticks—and is injected through a tiny incision on the lower part of the chest, similar to contraceptive devices that women have implanted in their arms. Once in place the Reveal LINQ™ can detect and monitor abnormal heart rhythms for up to three years. Implantation now takes a few in the world with a 3G phone minutes, with local anesthesia signal. Profound abnormalities alone; Dr. Oliver Segal has generate an email or text pioneered their implantation message to alert the patient’s outside of a catheterization lab physician that something is setting in London, using a wrong straight away. The device procedure room at the Harley can also detect episodes of Street Clinic Diagnostic Centre. atrial fibrillation, which can Patients are home within be very useful in patients Oliver Segal, M.D. 30 minutes or so and can go presenting with cryptogenic back to work if they wish. stroke (a stroke not attributable MRI scans can be performed with a to a specific cause) or after treatments Medtronic Reveal LINQ™ implanted. such as catheter ablation. The device automatically detects episodes The Medtronic Reveal LINQ™ of bradycardia (heart rate slower than is changing the landscape of diagnostic normal) or tachycardia (resting heart rate ECG monitoring and lowering the faster than normal) and wirelessly transmits threshold for using implantable devices this information every night to a monitor to diagnose patients correctly. Dr. Oliver kept in the patient’s bedroom; additional Segal and the Harley Street Clinic are transmissions can be made manually pioneering outpatient implantation if the patient has symptoms. The of this device, raising the acceptability of information is then transmitted to a this technique even further. secure website accessible only to the Oliver Segal, M.D. cardiologist; the monitor works anywhere things happen overseas. Diabetes is a chronic illness that can be affected by travel. A diabetic is more prone to infection and is subject to fluctuating blood sugar depending on diet, and traveling to exotic locales will likely involve a change in diet. A well-formed plan on how to manage diabetes while traveling is a must. People who are immuno-compromised, perhaps from having received a transplant in the past, or as a result of taking medication for rheumatoid arthritis or Crohn’s disease, are also more susceptible to infections that are endemic and their response to these infections is significantly different because their immune system is weakened. Even healthy people can have conditions to be concerned about—pregnancy is a consideration. I always recommend that pregnant women who are going to an area with malaria discuss it with their obstetricians and make sure that they are aware of the risks associated with malaria in pregnant women. It really involves being aware of the place you are going to, being aware of your own body and what is going on there and seeking the appropriate medical care. It is a three-pronged approach before travel. Travelers should be sure to pack a sufficient supply of any medication that they take normally and a small first aid kit: an antiinflammatory (ibuprophen, naproxen, or aspirin) band-aids, disinfectant, gauze, Benadryl, hydrocortisone cream, and depending on the destination, a mosquito repellent can be very crucial. In general we Health News | Fall/Winter 2014 recommend something that has between 20 and 30 percent Deet. Those of us who live in the northeast or in areas with tickborne illnesses know that these can be very helpful and sometimes life saving. If one will be primarily outdoors in areas where there is a high risk of mosquito-borne illnesses they should definitely take a mosquito netting, available from any camping store; some are even sprayed with a chemical called permethrin, which helps kill mosquitoes. If the purity of the water is in question, I always recommend drinking bottled water, brushing teeth with it and using it to make ice in their hotel room. Alternatively, a filter from a camping store can be used to purify water. Joseph El Khoury, M.D. 5 Mark Weidenbaum, M.D. Continued from page one to earn his medical degree at Columbia University College of Physicians and Surgeons in 1981. He then trained for two years in General Surgery at Roosevelt Hospital (New York), after which he completed a residency in Orthopedic Surgery at Columbia’s Presbyterian Medical Center (New York) and a Fellowship in Scoliosis and Spine Surgery at Rush-Presbyterian–St. Luke’s Medical Center in Chicago. Dr. Weidenbaum has received several prestigious grants from the Orthopaedic Research and Education Foundation, the National Institute of Health, and the Carroll Foundation to support his clinical and basic science research. Recognized internationally for his work on spinal deformity, Dr. Weidenbaum actively participates in the American Association of Orthopaedic Surgeons, the Scoliosis Research Society (SRS), and other leading professional organizations. He is a member of the SRS Board of Directors, and has been selected as the SRS Secretary. Dr. Weidenbaum is also a highly active Faculty Member and Course Co-Chair for the SRS, participating in numerous training courses held in Sarajevo, Bosnia; Valencia, Spain; and Calcutta, India. With an extensive number of peerreviewed publications in Spine, the Journal of Orthopedic Research, and the Journal of Biomechanics, as well as several textbook chapters to his name, it is no wonder that Dr. Weidenbaum is frequently invited to lecture and operate in locations throughout the United States, Europe, the Middle East, South America, and Asia. He has consulted for the New York Yankees and appeared several times on NBC’s The Today Show to discuss spine issues. Dr. Weidenbaum is part of a family of enthusiastic healthcare providers: his wife, Lisa Berke-Weidenbaum, is a nurse practitioner, and his middle daughter, Emily M. Weidenbaum, is a first year medical student at Columbia’s College of Physicians & Surgeons. 6 Lung Cancer Screening: The Benefits of Early Detection Continued from page one Over the past few decades, many studies have looked at the optimal imaging technique to screen for early lung cancer. Early studies in the 1980s, conducted throughout the US and Europe, failed to demonstrate any benefit to screening with chest X-ray, sputum analysis, or the combination. In the late 1990s and early 2000s advances in computed tomography (CT) allowed for several studies to be performed that first demonstrated utility of CT in screening for lung cancer. In the US, this has culminated in the National Lung Screening Trial (NLST), a multicenter trial, which concluded that low dose CT (LDCT) was superior to chest X-ray in detecting early-stage lung cancer. In that study, screening with LDCT in a highrisk population led to 20% fewer deaths from lung cancer than screening with chest X-ray. This remarkable difference was thought secondary to the ability of CT to detect more early stage cancers. Today, lung-screening programs perform CT scans of the chest with a low dose technique of radiation equivalent to only a few chest x-rays. What should you expect from joining a lung-screening program? Lung-screening programs will have dedicated staff members who can provide you with a risk assessment and advise you as to the potential risk and benefits of undergoing a low dose CT scan for detection. The LDCT examination takes about 5 minutes to perform, with the scan itself being done in a single breath hold. The scan is evaluated by an experienced radiologist and is given a suspicion score and recommendations for follow-up. Suspicion is based on the size of a nodule, its consistency, and any associated growth noted on follow-up examinations. The vast majority of the studies will be negative with recommendations for annual followup. It is important to understand that up to 15 to 20% of these studies may be considered “positive.” A positive study does not mean that a lung cancer was detected, but that an abnormality was identified on the CT that requires additional testing or a follow-up period shorter than one year. Only a small fraction of positive studies will represent cancer. (Figure 2) Positive studies that do not actually represent cancer (false positives) are a point of controversy in screening. It is the false positive examinations, the potential for unnecessary additional testing, and the possibility of treatment of cancers that would never have proven to be lifethreatening that need to be minimized to allow full adoption of lung screening. Lung Cancer Prevention & Risk Factors Whereas early detection allows for optimal therapy with the highest likelihood for cure, primary prevention should not be ignored. While controversy surrounds several potential risk factors of lung cancer, the link between lung cancer and smoking is clear, accounting for 80 to 90% of lung cancer deaths. For current smokers, cessation is the best method to not only lower risks of developing lung cancer, but also lowering the risk of stroke and heart disease. The process of quitting is very difficult and many screening programs will either have counselors available to help or be able to direct you to one. Additional risk factors for development of cancer include environmental factors such as contact with asbestos and radon as well as genetic factors such as a strong family history of lung cancer. Personal history of other cancers or lung diseases such as chronic obstructive pulmonary disease (COPD) also appear to be related. A link between lung cancer risk and second-hand smoking is related to the amount of exposure. As the amount of exposure to second-hand smoke is difficult to measure, the actual risk may not be easily known. These factors, if they apply to you, should be discussed with your physician when deciding on screening. Where should I go for screening? Your primary physician can help you decide and evaluate your risks for lung cancer. Many centers will require a prescription from your doctor for screening. Centers that do not require a prescription will have physicians available to discuss whether or not you are a candidate. A thorough review of your family and individual medical history, smoking history, and environmental exposures will be used to make this determination. Your screening center should follow an organized plan or protocol for follow-up. Suspicious findings may require further testing, such as tissue biopsy; thus, centers should also have access to physicians experienced with this. In addition to strict quality control to decrease screening harms, easy access to a multidisciplinary team of physicians comprised of pulmonologists (lung doctors), thoracic surgeons, and radiologists who can help direct your care is essential. Bradley B. Pua, M.D. Figure 2 CONTRIBUTORS Charles M. Jobin, M.D. Assistant Professor of Clinical Orthopedic Surgery Columbia University College of Physicians and Surgeons Assistant Attending NewYork-Presbyterian Joseph El Khoury, M.D., Massachusetts General Hospital Bradley B. Pua, M.D. Assistant Professor of Radiology Program Director, Interventional Radiology Fellowship Director, Lung Cancer Screening Program NewYork-Presbyterian/Weill Cornell For questions and membership information, please call 1-212-472-4444 or 1-800-634-3932 Oliver Segal, M.D. Consultant Cardiologist & Electrophysiologist The Harley Street Clinic Diagnostic Centre Health News | Fall/Winter 2014 Visit our website www.massgeneral.org/executivehealthservices 7 101 Merrimac Street - Suite 290 Boston, MA 02114-4719 © The Executive Registry Network. All Rights Reserved. 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