Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
FALL 2015 REPORTS AND BEST PRACTICES FROM ST. JOHN PROVIDENCE INSIDE PAGES 2Research aims to extend joint replacement life Crittenton Hospital Medical Center joins Ascension Health GWEN MACKENZIE Senior Vice President, Ascension Health/Michigan Market Leader St. John Providence Corporate Services Warren, MI 48092 (586) 753-0718 [email protected] 3First Baby-Friendly Hospital designated in Macomb County 4New unit specializes in care of the elderly 6Decompression surgery offers solution for Chiari malformation symptoms 7Study assesses treatment options for rare brain tumor in children 8Study evaluates King–Devick test for concussion in high school football players 9Patients with flu-like symptoms sought for international study 10SJP a research site for uncontrolled hypertension study IT’S OFFICIAL - AS OF OCT.1, 2015, CRITTENTON HOSPITAL MEDICAL CENTER is part of Ascension Michigan. The 290-bed acute care healthcare facility joins St. John Providence, Borgess, Genesys, St. Mary’s of Michigan and St. Joseph Health System as part of the statewide footprint of Ascension. Crittenton has been serving Oakland, Macomb and Lapeer Counties as an independent hospital since it opened in Rochester in 1967. The addition of Crittenton strengthens Ascension’s presence in Northern Oakland County, and will position it to participate with other members of Ascension in clinically integrated systems of care to manage the health of populations in partnership with insurers and other care providers. We have formed an integration team of Crittenton and Ascension Michigan leaders to oversee program and operational alignment. Together with other market leaders, we held town hall sessions with associates, physicians and volunteers on Oct. 1 and 2. 12Surgery to calf muscle may resolve plantar fasciitis 14POEM offers incisionless treatment for swallowing disorder 15Miniature device signals the future of pacemaker technology Copyright © 2015 St. John Providence The growth strategy for Crittenton includes immediate capital investments, aligning hospital service lines with Ascension Centers of Excellence, engaging primary care physicians, and making operational improvements and revenue enhancements. Program “cooperation” in such areas as occupational health, home health and retail pharmacy are being explored. continued on page 13 ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations UPDATES & INNOVATIONS / FALL 2015 1 Jean Meyer, MSN, RN President & CEO St. John Providence Editorial Board Michael C. Wiemann, MD President, Providence-Providence Park Hospital, Southfield Sr. Vice President St. John Providence Robert Hoban Interim President, St. John Hospital & Medical Center Senior Vice President Strategy & Business Development and Centers of Excellence H. Lee Bacheldor, DO Chief Medical Officer St. John River District Hospital Gary Berg, DO Chief Medical Officer St. John Macomb-Oakland Hospital, Warren Kevin Grady, MD, FCCP Chief Medical Officer St. John Hospital & Medical Center Scott Eathorne, MD President and CEO Together Health Network Gina Buccalo, MD Chief Medical Officer Partners in Care Medical Editor David Svinarich, PhD Vice President, Research St. John Providence [email protected] Publication Editor Theresa Vigiano Lead, Physician Marketing St. John Providence [email protected] 2 UPDATES & INNOVATIONS / FALL 2015 Research aims to extend joint replacement life DAVID MARKEL, MD Chief, Orthopedic Surgery and Market President, The CORE Institute Providence-Providence Park Hospital Southfield and Novi, Michigan (248) 349-7015 [email protected] ONE MILLION HIP AND KNEE REPLACEMENTS ARE PERFORMED IN THE US EVERY YEAR. Despite improvements in implant technology, patients are living longer and having initial implant surgery at younger ages. Thus, approximately 10 percent of patients outlive the usefulness of their implants and require implant revision surgery. Another reason patients might require revision surgery is due to an overaggressive immune system. Over time, friction between the mechanical parts of joint replacement implants produces tiny particles of wear debris. For some patients, the body’s reaction is an immune response, dispatching macrophage cells to destroy the particles. The macrophage cells also destroy some of the bone around the joint replacement, resulting in bone erosion. The response is not unlike that seen in normal bone turnover or severe osteoporosis, but in this case it is aggravated by the wear debris. The resorption of the bone ultimately causes joint replacements to become loose, and historically after 15 to 20 years, patients often need implant revision surgery. A possible solution comes from a familiar source: the antibiotic erythromycin. Over the past 10 years, researchers have confirmed that erythromycin is also effective in inhibiting particle-induced chronic inflammation in orthopedic settings. This is the same kind of wear that occurs in joint replacements, but it was unknown whether the inflammationfighting properties of erythromycin would affect bones. In the lab, our team discovered that when pre-osteoblastic cells (immature cells that can become boneproducing cells) were grown in the presence of continued on page 7 First Baby-Friendly Hospital designated in Macomb County PAULA SCHRECK, MD, IBCLC Breastfeeding coordinator, St. John Hospital & Medical Center Medical Director, St. John Breastfeeding Support Services and the Outpatient Breastfeeding Clinic Detroit, Michigan (313) 343-3146 [email protected] ST. JOHN MACOMB-OAKLAND HOSPITAL, WARREN, IS THE FIRST HOSPITAL IN MACOMB COUNTY TO ACHIEVE BABYFRIENDLY DESIGNATION. More than 1,100 deliveries take place annually in the Birthing Center at St. John Macomb-Oakland Hospital, Warren. The community’s diverse population includes a large Chaldean and Arab-American refugee population and a large Bangladeshi population. Our challenges are language barriers, poverty and stress. The recent refugee families are vulnerable, unsettled, and were persecuted before they arrived in the U.S. Despite these unique obstacles, St. John Macomb-Oakland Hospital, Warren joined 286 U.S. hospitals in achieving the high standards required for Baby-Friendly designation, a challenging quality-improvement designation. Prior to receiving Baby-Friendly designation, the hospital had the KIMBERLY RONNISCH, RN, BSN, HNB-BC, MHA Director, Patient Care Services and director, Women’s Services, East Region St. John Hospital & Medical Center, Detroit, Michigan St. John Macomb-Oakland Hospital, Warren, Michigan (313) 343-7176 [email protected] lowest breastfeeding initiation rate in metropolitan Detroit. Today, the initiation rate is 75 percent. St. John Providence has invested significant time and resources in achieving the designation, including three hours of training for pediatricians and OB/GYN physicians and 20 hours of training for department nurses. Baby-Friendly designation is an important step in working toward culture change that views breastfeeding as normal and even “cool.” We encourage breastfeeding as a choice every mother can consider. When women learn the benefits and talk about breastfeeding with their health care team, many more are willing to try it. To achieve Baby-Friendly designation, St. John Macomb-Oakland Hospital, Warren established and adhered to the Ten Steps to Successful Breastfeeding. Developed by a team of global experts, these evidencebased practices increase breastfeeding initiation and duration: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2.Train all health care staff in the skills necessary to implement this policy. 3.Inform all pregnant women about the benefits and management of breastfeeding. 4.Help mothers initiate breastfeeding within one hour of birth. 5.Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6.Give infants no food or drink other than breast milk, unless medically indicated. 7.Practice rooming in – allow mothers and infants to remain together 24 hours a day. 8.Encourage breastfeeding on demand. 9.Give no pacifiers or artificial nipples to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations continued on page 5 UPDATES & INNOVATIONS / FALL 2015 3 St. John Macomb-Oakland Hospital, Warren Campus New unit specializes in care of the elderly MARILYN CITO, RN, BSN, MA ED Director of Nursing at St. John Macomb-Oakland Hospital, Director of Nursing and Patient Education, East Region, St. John Providence Warren, Michigan (586) 573-5030 [email protected] GEMMALYNN DIXON, RN, BSN, MBA Nurse Manager, Acute Care of the Elderly (ACE) Nursing Unit St. John Macomb-Oakland Hospital Warren, Michigan (586) 573-5522 [email protected] AFTER A HOSPITAL STAY, MANY OLDER ADULTS EXPERIENCE A DECREASE IN MOBILITY AND STRENGTH. The Acute Care of the Elderly (ACE) Unit at St. John Macomb-Oakland Hospital, Warren Campus, opened in July 2015 and is designed to prevent deterioration during a hospital stay and incorporate strength-building and socialization into every patient stay. Senior patients who were walking and completing activities of daily living prior to hospitalization often remain in bed for most of the time during a hospital stay. To address this concern on the ACE unit, physical therapy mobility techs visit patients who need minimal to moderate assistance, and get them up and walk them on the unit daily. Mobility techs are ideal for patients who don’t require physical therapy, but benefit from encouragement and minimal assistance. During multidisciplinary rounds in the morning, nurses identify patients who will benefit from this service and notify the tech responsible for walking the patient. The nursing unit has identified markers in the hallways so patients and staff can measure the distance the patient has walked. Vintage, nostalgic art of Detroit and surrounding cities line the unit hallways. These images, such as Olympia stadium, the Hudson’s building, the Boblo Boat and Mackinaw Bridge are familiar landmarks for many of our senior patients, who linger as they look at the images and reminisce with associates and family members. We find these simple additions to the unit increase the duration of time patients stay up, moving and socializing. In addition to nursing associates, the unit has a dedicated social worker and discharge planner who sees every patient during their stay to prepare for a successful transition from hospital to home or assisted living facility. Almost 90 percent of the unit nurses are Geriatric Resource Nurses (GRN) with additional training in care of the elderly. Our goals are to prevent setbacks and manage daily patient needs before physicians arrive. A dedicated nurse practitioner leads multidisciplinary rounds with the manager, nurses, social worker, and discharge planner on 4 UPDATES & INNOVATIONS / FALL 2015 CYNTHIA SHIELDS, MSN, NP-C Nurse practitioner, Acute Care of the Elderly (ACE) Nursing Unit St. John Macomb-Oakland Hospital Warren, Michigan (586) 576-4364 [email protected] ACE Unit Inclusion Criteria • Age 65 or older with an acute condition requiring medical/surgical care. Will accommodate patients 60 and above if census permits. • Admitted from home or assisted living facility (extended care facility patients may be considered). • Bedridden or hospice patients are not eligible. • Admitting diagnoses include: • TIA/seizures • Acute mental status changes/Alzheimer’s Disease/ dementia • Syncope • Degenerative nervous system disorders • Uncontrolled hypertension • Pneumonia/COPD/asthma/respiratory infections or failure • Pulmonary embolism • Gastrointestinal bleeding (GIB)/ulcers • Abdominal pain/gastroenteritis/small bowel obstruction • Urinary tract infection • Renal failure (non-dialysis) • Sepsis • Uncontrolled diabetes • Cellulitis • Deep vein thrombosis • Dehydration • Ataxia/weakness/balance problems/failure to thrive • Pressure ulcers • Minor surgical procedures (Patients with primary diagnoses of stroke, orthopedic or cardiac conditions are better matched for the units with nursing staff specifically trained to care for those conditions.) the floor daily. Rounds include reviewing labs, vital signs, replacing electrolytes, requesting medications, and if a patient is not active, contacting the mobility tech or physical therapy to increase mobility. Pharmacy also attends some multidisciplinary rounds and confers with physicians to detect opportunities to lower dosages or discontinue a medication. Our nursing staff rounds every two hours to ensure the patients’ needs are being met; we “bundle” continued on next page New unit specializes in care of the elderly continued from page 4 nursing care at night to avoid waking patients. Mealtime is another opportunity for patients to get up, and we ensure they leave bed to eat twice a day, when possible. A common Day Room is outfitted with chairs and tables for dining, playing cards and board games, and watching TV. Wii games, classic movies and music also interest patients and lead to socialization and active time out of their rooms. Special events take place regularly. Twice a week, patients are invited for short health and wellness talks. Manicures and movie night also generate high attendance. Aromatherapy, music therapy and pet therapy occur several times weekly. Family members benefit from the unit’s Community Resource Center, stocked with relevant and current information on home care options, home medical resources, and caring for their elderly loved one. A hard of hearing telephone is showcased in this area and can be ordered for patients after discharge, if a prescription is signed by the physician or nurse practitioner. Sleeper chairs in patient rooms enable family members to spend the night. Most patients are admitted through the St. John Macomb-Oakland Hospital, Warren, Emergency Department, while others are transferred from another unit, such as ICU or step-down. Stable patients can be directly admitted to the unit. Telemetry monitoring is available. We are collecting outcomes data on falls, pressure ulcers, and discharge destinations. Since opening, just two falls have occurred and the unit has remained restraint free. Nursing leaders have completed the Hartford Institute for Geriatric Nursing program, Nurses Improving Care for Healthsystem Elders (NICHE) program. As the unit continues to evolve, we are developing and investigating additional strategies and techniques to ensure the best possible outcomes and highest levels of patient satisfaction. The 24-bed unit has private and semi-private rooms. It is located on the fourth floor of St. John Macomb-Oakland Hospital, Warren, and accessible via the central tower elevator. Physicians are welcome to visit and tour the unit at any time. For more information or to admit a patient, call Gemmalynn Dixon, RN, BSN, MBA, nurse manager, (586) 573-5522 or Cynthia Shields, MSN, NP-C, nurse practitioner, (586) 576-4364. After business hours/weekends, contact the unit charge nurse, (586) 573-4364. First Baby-Friendly Hospital designated in Macomb County continued from page 3 The Ten Steps to Successful Breastfeeding are beneficial to all mothers and infants, not only those who are breastfed. Universal benefits include: • Adequate prenatal education ensures mothers come to the hospital to deliver with balanced, accurate information about infant feeding and can make informed choice. • Rooming-in after birth means babies are not taken from the room for routine tests, such as hearing tests, blood draws and weight assessments. Infants experience less stress, and mothers gain a deeper understanding of infant health care and their babies’ unique communication. Since babies are often active at night, mothers learn to rest during the day and get better quality sleep. • All mothers are offered the option to engage in skin-to-skin contact after birth. Research shows skin-to-skin contact decreases infant stress, increases breastfeeding success, decreases health concerns for mothers and babies, and decreases the mother’s perception of pain. • Staff encourages feeding on demand; babies are fed according to need and assuring a minimum of eight feedings in 24 hours. We have engaged several community organizations, such as the Chaldean American Ladies of Charity, Macomb County WIC and the Infant Mortality Project at St. John Providence, to support the Baby-Friendly initiative and provide resources for women as they continue to breastfeed at home. We started an outpatient breastfeeding clinic, and have a Chaldean Arabic-speaking lactation consultant to provide follow-up care in. An Arabiclanguage support group for mothers meets at a Chaldean facility in nearby Troy, and the Ronald McDonald foundation provided support to purchase breast pumps. In addition, a grant from the Michigan Department of Community Health allowed us to translate most educational materials into Arabic. St. John Hospital & Medical Center was the first in the system to receive Baby-Friendly designation. Expanding the designation supports a coordinated approach to patient care and sharing of best practices. Providence-Providence Park Hospital, Southfield and Novi are currently working to achieve Baby-Friendly designation. Baby-Friendly Hospital Initiative (BFHI) is a global program launched in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). To learn more, log on to https://www. babyfriendlyusa.org. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations UPDATES & INNOVATIONS / FALL 2015 5 Decompression surgery offers solution for Chiari malformation symptoms HOLLY GILMER, MD Neurological Surgery and Pediatric Neurological Surgery St. John Hospital & Medical Center Providence-Providence Park Hospital Detroit and Southfield, Michigan (877) 784-3667 [email protected] CHIARI MALFORMATIONS ARE STRUCTURAL DEFECTS THAT OCCUR IN THE CEREBELLUM, the part of the brain that controls coordination and muscle movement. Previous estimates were that malformations occur in about one in every 1,000 births, but increased use of diagnostic imaging indicates that the disorder may be more common. Normally the cerebellum and parts of the brain stem sit in the posterior fossa of the skull, above the foramen magnum, or the opening to the spinal canal. In individuals with Chiari malformations, the posterior fossa is abnormally small and misshapen. It presses on the brain, forcing it downward and causing the cerebellar tonsils to protrude into the spinal canal. This blocks the flow of cerebrospinal fluid to the brain, which can lead to hydrocephalus and/or increased intracranial pressure. It also causes direct pressure on the brain stem and upper spinal cord. Chiari malformation is diagnosed by MRI. When deciding if surgery is an option, the extent of the herniation of the brain into the spine is not as important as the symptoms the patient experiences. For some adults, symptoms are not severe and they do not require surgery. Chiari malformation is also sometimes an incidental finding on MRI, and the person is asymptomatic. Chiari malformations are classified as types I-IV, as described by the Austrian pathologist Hans Chiari based on their anatomic features. The most common type is Chiari I. It is often associated with scoliosis and syringomyelia, and may not cause problems during childhood. Chiari II is associated with myelomeningocele, or spina bifida. It is most commonly diagnosed in infants or on prenatal ultrasound, and is associated with hydrocephalus. Infants with Chiari may have symptoms which include difficulty swallowing, irritability when being fed, excessive drooling, a weak cry, frequent gagging or vomiting, arm weakness, breathing problems, developmental delays, and poor weight gain. Older children experience headaches, dizziness, ringing in the ears, and problems with vision. One of the most frequent presentations is scoliosis with none of these symptoms except infrequent headaches. Some children 6 UPDATES & INNOVATIONS / FALL 2015 In patients with Chiari malformation, the posteria fossa is abnormally small and misshapen, forcing the cerebellar tonsils down into the spinal canal, as noted in this patient MRI. may not have noticeable symptoms until adolescence or adulthood. In teen and adult years, problems can include persistent headaches, neck pain, and weakness and/or numbness and tingling in the arms and legs. Adult symptoms include neck pain, balance problems, muscle weakness, numbness or other abnormal feelings in the arms or legs, dizziness, vision problems, difficulty swallowing, ringing or buzzing in the ears, hearing loss, vomiting, insomnia, or headache made worse by coughing, laughing, or straining. Hand-eye coordination and fine motor skills may be affected. Symptoms can change over time depending on the build-up of cerebrospinal fluid and pressure on the brain, spinal cord, and nerves. The surgical treatment to correct the compression involves removing a portion of the skull and usually part of the C1 vertebra. The cerebellar tonsils are usually partially removed. We always open the covering of the brain (dura) and use an expansion graft to make the dura larger and give the brain more room to expand. Decompression surgery returns the normal flow of spinal fluid and relieves some or all of the symptoms by relieving pressure from the brain stem. The surgery also helps decompress the venous circulation, which in turn improves resorption of spinal fluid. This procedure usually keeps symptoms, particularly headaches in adults, from getting worse and frequently results in complete resolution of some symptoms. In approximately 500 cases since 2000, patients have had greater than 90 percent improvement or resolution of symptoms following surgery. We perform decompression surgery at St. John Hospital & Medical Center. For more information, visit http://bit.ly/1G0lWmF. To refer a patient for diagnosis of Chiari malformation or evaluation for decompression surgery, call (877) 784-3667. Study assesses treatment options for rare brain tumor in children PAUL CHUBA, MD, PHD, FACR Chief of Radiation Oncology St. John Macomb-Oakland Hospital Warren, Michigan (586) 573-5186 [email protected] PRIMARY GERM CELL TUMORS (GCTS) ARE RELATIVELY UNCOMMON MALIGNANCIES in the central nervous system, making up less than four percent of brain tumors in children in Western countries, with nearly 90 percent occurring before age 20. A subgroup of these malignancies, nongerminomatous germ cell tumors (NGGCTs) are quite rare; NGGCTS are less sensitive to radiation therapy. In the past, five-year survival rates for this disease had been in the range of 30 to 40 percent. We participated in a national study conducted by the Children’s Oncology Group, designed to evaluate how treatment that included adjuvant chemotherapy would affect tumor response and survival outcomes in children with newly diagnosed NGGCTs. The study began in 2001 with follow-up over several years. The course of chemotherapy, administered prior to craniospinal irradiation, was intended to reduce measurable disease in order to increase the effectiveness of the radiotherapy. The choice of drugs for the adjuvant chemotherapy was informed by success observed in the treatment of similar germ cell tumors occurring more commonly in areas other than the central nervous system, particularly in the ovaries and testes. The schedule for administering the therapy was also unique to this study. Patients received six courses of intravenous chemotherapy on alternating 21-day cycles. Cycles one, three, and five consisted of carboplatin (day one) plus etoposide (days one through three). Cycles two, four, and six consisted of ifosfamide and etoposide (both on days one through five). Granulocyte colony-stimulating factor was given after each cycle. Evaluating the effects of adjuvant chemotherapy Determining the level of response to this chemotherapy approach was the study’s primary objective. The secondary objective was to establish both event-free and overall survival rates for the patients in the trial. Response was measured by three-dimensional MRI images of the tumor sites, and characterized as complete, partial, no response (stable disease), or negative response (progressive disease), based on changes in the size of tumors. Depending on a patient’s response to this step, studyindicated treatment could also include second-look continued on page 11 Research aims to extend joint replacement life continued from page 2 erythromycin, the erythromycin promoted bone cell growth. Additional studies showed that when we simulated a joint replacement by placing a titanium pin into an animal bone and exposed the pin/bone to small plastic “wear” particles, the oral erythromycin made the bone become more stable and prevented osteolysis, or bone resorption. Our team has most recently examined the effect of oral erythromycin on implant stability for patients undergoing hip or knee joint replacement revision surgery. After giving patients erythromycin before the revision surgery, we examined changes in their tissues at the time of surgery for evidence of a positive biologic response via markers in the blood and tissues. The erythromycin had a positive effect. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations A long-term goal is to develop a delivery system that brings the erythromycin directly to bone by using nanofibers attached to the implant. Our work focuses on infusing these very thin fibers with erythromycin and potentially spinning them around the metallic joint replacement implant. Once in place, the “coated” parts could deliver erythromycin slowly, strengthening bone over time, encouraging greater attachment between the bone and implant, and delaying or even eliminating bone loss. We are in the very early stages of what could be an important development in joint replacement technology. Our goal is to make joint replacements a permanent solution for joint pain. UPDATES & INNOVATIONS / FALL 2015 7 Study evaluates King–Devick test for concussion in high school football players MICHAEL SHAW, PHD Director, Research and Clinical Trials-Osteopathic Division St. John Macomb-Oakland Hospital Warren, Michigan (248) 967-7791 [email protected] IN HIGH SCHOOL FOOTBALL, PLAYERS RISK CONCUSSION AND OFTEN PRESSURE THEMSELVES to continue to play despite injury. It is critical to remove a concussed athlete from play in order to prevent further damage and keep the athlete from returning to play until they have made a full recovery. Many on-field tests for concussion are subjective, relying on the assessment of a trained professional to diagnose concussion and remove the player from competition. Repetitive brain injury can lead to consequences later in life, including anxiety, depressive disorders and chronic traumatic encephalopathy (CTE). Athletes who have had one concussion are more susceptible to another. This fact makes it even more crucial to detect concussion, remove athletes from play immediately, and seek medical attention. DANIEL SEIDMAN, DO Chief Resident, Family Medicine St. John Macomb-Oakland Hospital Warren, Michigan (586) 582-7550 [email protected] Our study was the first to evaluate the King-Devick test as a concussion screening tool for high school football players, and was recently published in the Journal of the Neurological Sciences (J Neurol Sci. (2015), http://dx.doi. org/10.1016/j.jn). The King-Devick test is a reliable tool that that relies on an objective measure: number reading. An oculomotor test originally designed for reading evaluation, it consists of three cards with a series of numbers printed on them. The test screens for saccades (eye movements), attention, concentration, speech/ language, and other correlates of sub-optimal brain function. The test administrator times the players as they read the numbers. Each card is more difficult to read. The King-Devick test was previously examined as continued on next page Individual players with concussion Baseline cumulative read time(s) 8 Sideline cumulative read time(s) Sideline percent baseline (%) Repeat (end of season) read time(s) End of season percent baseline Player 1 42.4 65.7 155.0 42.1 99.3% Player 2 44.5 51.0 114.6 43.7 92.8% Player 3 58.3 89.9 154.2 61.8 106.0% Player 4 35.0 73.6 210.3 60.6 173.1% Player 5 47.5 92.1 193.9 60.8 128% Player 6 59.1 90.2 152.6 58.4 98.8% Player 7 43.3 56.4 130.3 42.9 99.2% Player 8 47.1 54.1 114.9 NA — Player 9 54.7 66.2 121.0 NA — UPDATES & INNOVATIONS / FALL 2015 NA = lost to follow-up (quit football) Patients with flu-like symptoms sought for international study RODGER MACARTHUR, MD Infectious Disease and Internal Medicine specialist Providence-Providence Park Hospital Southfield, Michigan (248) 552-0620 [email protected] EVERY YEAR, BETWEEN FIVE AND 20 PERCENT OF THE US POPULATION CONTRACTS INFLUENZA. During the upcoming flu season, St. John Providence will again participate in FLU PLUS 002, a worldwide study funded by a division of the National Institutes of Health (NIH) to find out more about influenza. This observational study allows participants to use any treatment they wish for their symptoms. With these data, we’ll learn about various strains of the influenza virus that circulate in different parts of the world and correlate the information with individual health histories. We’ll also find out about the virulence of certain strains, discover which strains are geographically limited, and identify specific MARTI FARROUGH, BSN, RN Project Director Providence-Providence Park Hospital Southfield, Michigan (248) 552-0620, ext. 2874 [email protected] strains of the virus that are associated with poor clinical outcomes. The study began in November 2014 and continued through mid-March 2015. It will start again in November 2015 and continue through mid-March 2016. After this year, the NIH expects to continue the study for one to two continued on page 11 Study evaluates King–Devick test for concussion in high school football players continued from page 8 a removal-from-play device in college football, mixed martial arts and rugby, but had not been evaluated for use in younger, adolescent athletes who are more prone to concussion. We studied football players at four area high schools where St. John Providence employs athletic trainers: Grosse Pointe South, Chippewa Valley, L’Anse Creuse and L’Anse Creuse North. Prior to the beginning of the season, we recorded a baseline time for the King-Devick test with each player. Our team followed more than 350 players throughout the season, attending every game and practice. When a player suffered a suspected concussion, a member of our team administered the test on the sidelines in a matter of minutes. Players who had suffered a concussion performed poorly on the second testing, adding significant time to their baseline score. (See table on facing page.) In 100 percent of cases where the time was significantly longer, subsequent medical testing confirmed the presence of a concussion. Standard protocol among trainers and coaches is the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test. It is the most-widely used and most scientifically validated computerized concussion evaluation system. A disadvantage is that it cannot be administered on the sidelines. Players are out for the remainder of the game. In contrast, the King-Devick test can be administered by a trained layperson such as a coach, teacher, parent or volunteer. It takes only minutes to perform and is portable, so it can be administered on the sidelines. This study was only possible due to our team of 20 dedicated co-investigators that included residents, medical students and trainers from the physical rehabilitation department at St. John Providence. In the 2016 football season, we plan to study the King-Devick test with younger football players – those in “pee-wee” leagues – to evaluate its effectiveness in this age group. There is little research on concussion incidence in younger athletes, because there are typically no trained professionals on the field to evaluate them. The King-Devick test is inexpensive and commercially available for purchase. Individuals can be trained to administer it in just 15 minutes. It is a valuable tool for any contact sport where players are at risk for concussion. Contact Michael Shaw, PhD, at (248) 967-7791 or michael. [email protected] for information on how to purchase the test. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations UPDATES & INNOVATIONS / FALL 2015 9 SJP a research site for uncontrolled hypertension study SHUKRI DAVID, MD Physician Chair, Heart & Vascular Center of Excellence, St. John Providence Southfield and Novi, Michigan (248) 552-9858 [email protected] PROVIDENCE-PROVIDENCE PARK HOSPITAL, SOUTHFIELD, HAS BEEN SELECTED AS A RESEARCH SITE FOR THE MEDTRONIC SPYRAL HTN GLOBAL CLINICAL TRIAL PROGRAM, a unique, phased clinical trial studying renal denervation in patients with uncontrolled hypertension. The SPYRAL HTN trial investigates the impact of multielectrode renal denervation with and without the addition of antihypertensive medications. There are two arms of the study, ON MED and OFF MED. Each group will include approximately 100 patients internationally with moderateto high-risk hypertension. Patients enrolled in either arm of the study may be randomized to receive renal denervation or be in a control group, which does not receive the therapy. Providence-Providence Park Hospital, Southfield, is one of approximately 20 centers in the USA and globally to conduct the study. The SYMPLICITY HTN-3 trial, conducted from 2012 to 2014, was a precursor of the SPYRAL HTN trial. Providence-Providence Park Hospital, Southfield was a site for that study as well. The focus of the earlier study was treatment for a resistant population, while the current study is designed to isolate the effect of renal denervation on blood pressure reduction and address the confounding factors encountered in the previous clinical trial, including medication, adherence, patient population and procedural variability. The two arms of the study are: • SPYRAL HTN-OFF MED, which will examine the effect of renal denervation alone on hypertensive patients without the effect of anti-hypertensive pharmaceutical agents. • SPYRAL HTN-ON MED, which is designed to examine the effect of renal denervation on hypertensive patients with a prescribed set of anti-hypertensive medications. Renal denervation is intended to lower blood pressure by targeting renal nerves. The Symplicity system consists of a flexible catheter and proprietary generator. In an endovascular procedure, we insert the catheter into the femoral artery in the upper thigh and thread it into both renal arteries. Once the catheter tip is in place within the SUSAN STEIGERWALT, MD Director, Resistant Hypertension Clinic Providence Heart institute Nephrology and Internal Medicine Specialist Providence-Providence Park Hospital Southfield and Novi, Michigan (313) 549-9523 [email protected] renal artery, we activate the Symplicity generator to deliver controlled, low-power radio-frequency energy to deactivate surrounding renal nerves. This is intended to reduce hyper-activation of the sympathetic nervous system for an extended duration (months to years), which is an established contributor to chronic hypertension. The procedure requires an overnight stay. Eligibility Criteria The primary eligibility criteria for the SPYRAL HTN-OFF MED study include: • Seated office systolic blood pressure of ≥ 150 mm Hg and < 180 mmHg and a diastolic blood pressure ≥ 90 mmHg in the absence of anti-hypertensive medications • An eGFR of greater than 45 mL/min/1.73m2 • 24-hour ambulatory systolic blood pressure measurement of ≥140mmHg and <170 mmHg • No hemodynamically significant (<50 percent) renal artery stenosis If a patient is currently being treated for high blood pressure, we will temporarily discontinue antihypertensive drugs to allow study of the impact of renal denervation in the absence of antihypertensive medications. There is close medical follow up and if at any time a patient blood pressure elevates above a safety threshold, they will be restarted on medications. Medications will be started to keep blood pressure below 140/90 after three months regardless of whether the patient received the denervation therapy or not. The primary eligibility criteria for the SPYRAL HTNON MED study include: • Seated office systolic blood pressure of ≥ 150 mmHg and < 180 mmHg and a diastolic blood pressure ≥ 90 mm Hg while adhering to three anti-hypertensive medications of specified classes (dihydropyridine, ACEinhibitor/ARB, thiazide diuretic) • An eGFR of greater than 45 mL/min/1.73m2 • 24-hour ambulatory systolic blood pressure measurement of ≥140mmHg and <170 mmHg • No hemodynamically significant renal artery stenosis continued on page 13 10 UPDATES & INNOVATIONS / FALL 2015 Patients with flu-like symptoms sought for international study continued from page 9 more flu seasons. The St. John Providence research team finds interested participants primarily through local emergency departments and urgent care clinics. The only criteria to participate are a temperature of 100.4 or higher or feeling feverish, and a cough and/or sore throat. Individuals do not need to have confirmed flu. Participants may include patients, staff, visitors, or others. They first meet with a researcher and provide a history of their symptoms, other health problems and medications, and give a blood sample, which will be used for influenza testing. Researchers also take throat and nasal swabs to verify flu and identify the strain. Over the next 14 days, participants keep a “flu diary,” checking off the symptoms they experience. At their second visit, participants bring their flu diaries with them. Researchers collect a blood sample and information about any hospitalizations, complications or new health problems that arose because of their flu symptoms. Flu Genomics study We are also conducting the Flu Genomics study, a substudy to FLU PLUS 002. Participants give an extra blood sample for genetic testing. We will examine patient DNA and correlate it with patient health information and flu strain. The intent is to learn more about whether certain genetic factors make people more or less susceptible to flu and secondary health problems caused by the virus. Results of the genomic data will be used to identify genetic markers for influenza and potentially make flu prevention and treatment far more specific. To refer a patient with flu-like symptoms for study participation, contact Project Director Marti Farrough at (248) 552-0620, ext. 2874, or email [email protected]. Study assesses treatment options for rare brain tumor in children continued from page 7 surgery, high-dose chemotherapy, and peripheral blood stem cell rescue prior to craniospinal irradiation. Patients whose tumors showed complete or partial response, with or without second-look surgery, proceeded directly to craniospinal irradiation. Overall, adjuvant induction chemotherapy produced a 69 percent objective response rate (complete or partial) in the evaluable patients. Of those evaluated by the Quality Assurance Review Center, a positive response rate of 87 percent was reported. A chemotherapy treatment that was expected to reduce tumors preparatory to radiotherapy demonstrated that it was sufficient in some cases to eliminate NGGCTs and other germ cell tumor elements, with examination showing residuals that included teratomas, fibrosis, or no evidence of tumor. Furthermore, for the 102 eligible patients in the study, the five-year event-free and overall survival rates were 84 percent and 93 percent, respectively. Evaluating the data gathered in the trial In many ways, this study is now the gold standard for treatment of nongerminomatous germ cell pediatric brain tumors. The report recently appeared in the Journal of Clinical Oncology (JCO Aug 1, 2015: 2464-2471). More than 100 children and young adults were enrolled in the group, making it the largest controlled trial for this type of tumor. The survival rates are the highest achieved in any cooperative group trial that has been done in this disease. In addition, particular attention was paid to quality assurance review of the trial’s findings. For the first time, all the MRI images of patients with the same rare brain tumor are in one place. Our team has all their surgical findings, pathology reports, and the details of radiotherapy, and we know all their outcomes. The data set produced by the study should serve as the backbone of follow-up research and as a guide for treatment in the future. Already, analysis is underway to correlate the MRI images with the effects of treatment on these cases. The steps taken in quality assurance will allow future trials to draw on these results in confidence, and more study will lead to adjustments in both the volume and the dose of radiotherapy to get the best outcomes with the least side effects. To refer a patient, call Radiation Oncology Specialists, PC, at (586) 573-5186. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations UPDATES & INNOVATIONS / FALL 2015 11 Surgery to calf muscle may resolve plantar fasciitis NEAL MOZEN, DPM, FACFAS Podiatrist and podiatric surgeon Providence-Providence Park Hospitals Southfield and Novi, Michigan (248) 258-0001 [email protected] PLANTAR FASCIITIS RELEASE IS TRADITIONAL SURGICAL TREATMENT FOR PLANTAR FASCIITIS, but it may not offer patients relief from severe heel pain. For many patients, it is not the plantar fascia, but tight calf muscles and a condition called equinus that causes their heel pain. Gastroc recession surgery releases tension on the calf muscles and Achilles tendon, and in most cases, offers patients relief when conservative treatments have failed. In a retrospective study, researchers compared 30 patients with chronic plantar This cadaveric view demonstrates fasciitis who underwent the continuity of the Achilles tendon plantar fasciitis release with and the plantar fascia. 30 patients who underwent gastroc recession to treat chronic plantar fasciitis. Both groups were matched in terms of previous treatments and time from onset of Intra-operative views of endoscopic symptoms to surgery. Just gastroc recession, before (left) 60 percent of patients in the and after. plantar fasciotomy group had satisfactory results compared with 95 percent of the patients in the gastroc recession group. Gastroc recession patients resumed work and sports an average of seven weeks faster than the plantar fascia release group, and functional and pain scores were considerably better for gastroc recession with fewer complications. Demonstration of the silfverskiold test, a basic test for the source of (Int Orthop. 2013 Sep; 37(9): equinus. When upward bending 1845–1850. 10.1007/s00264motion of the ankle joint is limited 013-2022-2) to less than 10 to 15 degrees, equinus is usually present. 12 UPDATES & INNOVATIONS / FALL 2015 THOMAS BELKEN, DPM, AACFAS Podiatrist Providence-Providence Park Hospitals Southfield and Novi, Michigan (248) 258-0001 [email protected] There is more than a 20-fold increased chance for developing plantar fasciitis when equinus is present, and a direct correlation between increased tension on the Achilles tendon and increased tension on the plantar fascia. Because the Achilles tendon is continuous with the plantar fascia, it is crucial to also screen for equinus when treating patients for plantar fasciitis. (Podiatry Today, 2015 May; 28(5). http:// www.podiatrytoday.com/closer-look-gastroc-recessionplantar-fasciitis) Plantar fasciitis affects one in 10 people during their lifetime. The tough, fibrous plantar fascia ligament runs between the heel bone and the base of the toes, where it fans out. It becomes inflamed in patients with plantar fasciitis and typically worsens without treatment. Patients can develop foot, knee, hip and back problems due to gait changes. Foot pain causes a drop in activity, which has a negative impact on quality of life and overall health and contributes to many chronic health conditions. In our practice, we first treat patients with plantar fasciitis conservatively, with posterior stretching exercises, night splints, injection therapy with needling, orthotic therapy, platelet rich plasma (PRP) and shockwave treatment. We encourage patients to shorten their stride length to allow the knee to absorb more shock than the heel, and advise on proper footwear for both inside and outside the house. Working with primary care physicians, we help patients avoid strong corticosteroids when possible, as they cause atrophy of the essential fat pad in the heel. We also advise patients to maintain a healthy weight. For most individuals presenting with plantar fasciitis, a combination of these strategies will resolve their symptoms. However, when patients do not improve with conservative treatment, and the upward bending motion of the ankle joint is limited to less than 10 to 15 degrees, equinus is usually present. These patients lack the flexibility to bring the top of the foot toward the front of the leg. Even wearing orthotics can be intolerable when the foot can’t function normally or be held at the proper angle. The gastrocnemius and the soleus are two muscles that make up the calf. The gastroc is the larger of the two, and continued on next page Surgery to calf muscle may resolve plantar fasciitis continued from page 12 the gastroc tendon combines with the soleus tendon to form the Achilles tendon. In gastroc recession surgery, we lengthen the aponeurosis, which is the fibrous band just below the gastrocnemius muscle belly. Distally the gastroc aponeurosis merges with fibers from the soleus muscle to form the Achilles tendon. Because the gastrocnemius aponeurosis sits on top of the well-vascularized soleal muscle, the aponeurosis usually heals in its lengthened position relatively quickly. Using local anesthesia and IV sedation, we make a small incision at the back-inside of the mid-calf, locate the gastroc aponeurosis, and lengthen it with endoscopic instrumentation. The cut aponeurosis heals in an elongated position helping relieve contracture to the Achilles tendon and reducing mechanical stress to the heel and plantar fascia. Following surgery, patients stay off their foot for three days, then walk in a supportive boot for three weeks. At six weeks, we typically see a dramatic improvement in pain. Full activity may require up to three months. Releasing tension on the gastroc relieves mechanical stress on the foot. By combining gastroc recession with other supportive measures, such as orthotic therapy, activity modifications and supportive shoes, we can create the proper environment to allow heel pain symptoms to further resolve. While plantar fascial release remains a common treatment, and for some patients may be indicated, in other patients with equinus contracture, it targets the wrong anatomy and in all patients, weakens the arch of the foot. The arch acts as a spring mechanism and absorbs shock. Cutting the plantar fascial ligament can cause an unstable foot structure, foot fatigue, and limitations on patient activity. Some patients develop other conditions as a result, such as bunions and hammer toe, due to increased mechanical stress on the foot. We generally do not see foot instability as a result of gastroc recession. We have been performing endoscopic gastroc recession for almost 15 years and are one of the pioneering practices for the procedure in this area. Crittenton Hospital Medical Center joins Ascension Health Medtronic SPYRAL HTN studies renal denervation in uncontrolled hypertension continued from cover continued from page 10 Crittenton will continue to have its own medical staff and by-laws, as do other hospitals within St. John Providence and Ascension Michigan. Crittenton Hospital Medical Center will not become a Catholic hospital. However, as a member of Ascension, Crittenton will follow and adhere to the Ethical and Religious Directives (ERDs) for Catholic Health Care Services (http://www.usccb.org/about/doctrine/ ethical-and-religious-directives/) as issued and revised from time to time by the United States Conference of Catholic Bishops. Like the other Ascension Michigan hospitals and health systems, Crittenton will retain its current name. Crittenton is a distinct Ascension Michigan ministry, not part of either St. John Providence or Genesys. To Refer a Patient Recruitment for this study is ongoing. For more information or to refer patients, contact Jean Kelly, RN, (248) 849-3369, or [email protected]. Refer patients with foot and heel pain that has not resolved with rest or conservative treatment by calling (248) 258-0001. To learn more about the clinical trial, visit http://www. spyralhtntrials.com. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations Submit your story ideas for Updates & Innovations If you are conducting research, performing new or advanced medical procedures or services, using the latest technology or providing a service not typically offered in southeast Michigan, please contact Theresa Vigiano, the editor of Updates & Innovations, at (248) 331-4794, or [email protected]. We are constantly seeking story ideas from St. John Providence medical staff to highlight your innovations and share them with referring physicians. UPDATES & INNOVATIONS / FALL 2015 13 POEM offers incisionless treatment for swallowing disorder MOHAMMED BARAWI, MD Medical director, Endoscopy Unit, and division head, Department of Gastroenterology St. John Hospital & Medical Center Detroit, Michigan (313) 343-7020 [email protected] PATIENTS UNABLE TO SWALLOW DUE TO ACHALASIA OR SPASTIC ESOPHAGEAL DISORDERS not responding to medical therapies may be candidates for Peroral Endoscopic Myotomy (POEM). POEM is a highly specialized procedure and offered at only a few locations in the United States. St. John Hospital & Medical Center is the only location in southeast Michigan offering POEM. Approximately 2,000 people in the US are diagnosed with achalasia each year. Achalasia is caused by a tight sphincter muscle, which doesn’t relax enough to allow food to pass from the esophagus into the stomach. The condition compromises peristalsis of the esophagus, resulting in motility issues and making it difficult for food to move into the stomach. The condition occurs most often in middle-age and older adults, whose symptoms include trouble swallowing, regurgitation, heartburn, chest pain, cough and weight loss. Before POEM After POEM To perform the procedure, we introduce the endoscope through the mouth into the esophagus, where we make an incision in the mucosa of the esophagus. Using a knife on the tip of the endoscope, we tunnel through the esophagus wall to access to the muscle layers below. Next, we perform the myotomy by cutting and partially removing the inner circular of muscle layer from the lower esophageal 14 UPDATES & INNOVATIONS / FALL 2015 sphincter and the upper part of the stomach. The myotomy relieves the tightness of the sphincter so food can pass normally through the esophagus. Patients stay overnight and after a barium swallow test the next morning, are discharged on a liquid diet for three days. After that, they can begin to eat normally. Patients typically experience a dramatic improvement in quality of life, and are usually able to eat and drink normally just days after the procedure. Following the procedure, one of our patients, who had been unable to swallow for 20 years, was brought to tears when he could drink a cup of water. Another patient told us the procedure changed his life because he can now sleep lying flat. Prior to POEM, surgeons performed the myotomy through a large open incision in the chest or abdomen. More recently, we performed laparoscopic esophageal myotomy through several small incisions. However, POEM involves no abdominal incision, no chest incision, and a minimal stay in the hospital. Because the surgery is incisionless, patients experience no blood loss. The cost to perform POEM is lower than open or laparoscopic surgical approaches. Other non-surgical treatment options include nitrates or calcium channel blockers, but these typically offer only short-term relief. Botox injections are another option, but they must be repeated every six to nine months and should be used with caution, as they can cause fibrosis and make surgery more difficult in the future. Patients are seen in the newly renovated and expanded Elaine E. Blatt Endoscopy at St. John Hospital & Medical Center. The unit is twice as large as the previous area and includes additional procedure rooms and technology. It provides patients superior privacy and comfort, and was essential to accommodate high patient volumes and advanced procedures, such as POEM, that physicians at St. John Hospital & Medical Center are offering. To refer a patient, call the Elaine E. Blatt Endoscopy Department at St. John Hospital & Medical Center, (313) 343-7020. Miniature device signals the future of pacemaker technology SOHAIL HASSAN, MD Director of Electrophysiology St. John Hospital & Medical Center Detroit, Michigan (586) 777-7772 [email protected] THE ELECTROPHYSIOLOGY TEAM AT ST. JOHN HOSPITAL & MEDICAL CENTER WAS THE FIRST IN SOUTHEAST MICHIGAN TO IMPLANT THE NANOSTIM, a wireless, non-surgical cardiac pacemaker placed directly into the right ventricle of the heart. St. Jude Medical’s Nanostim is one of the most exciting advances yet in pacing technology, and has the potential to transform how heart rhythm patients are treated. Within seven months of the first Nanostim implant in the US, we brought it to patients locally. We have implanted 14 leadless pacemakers so far, with no complications or dislodgements, with some patients followed up for more than a year. Patient experience has been excellent and their sharing of experiences has helped more patients feel comfortable with the technology. Patients report that lack of a surgical scar on the chest and lack of hardware under the skin below the collar bone are major benefits. In addition, Nanostim does not restrict mobility of the arm. Currently, Nanostim is only available in the US through the LEADLESS II trial, an international clinical study to evaluate the safety and effectiveness of the pacemaker. St. John Providence is one of 55 participating centers worldwide. The study is expected to enroll approximately 670 patients total as St. Jude Medical works toward FDA approval. Every year in the US, surgeons implant more than 700,000 pacemakers to regulate the heart’s rhythm. With traditional pacemakers, all patients have a chest incision and a lump in the chest. In addition to a pulse generator that houses a battery and small computer, traditional pacemakers have one to three leads. Surgeons implant the device through an incision in the upper chest and insert the leads through one or more of the veins in the heart. Although the incidence of pacemaker complications is relatively low (about four percent), when complications occur, they typically happen in the pocket where the pacemaker is implanted or with the leads. In about one percent of patients, the pocket becomes infected and in about three percent of patients, the leads move out of place causing complications. Research shows that six out of 10 patients experience reduced mobility in the shoulder region where the pacemaker is implanted. In contrast, Nanostim has no leads, doesn’t require surgery and leaves no scar or lump in the chest. It works much like a traditional pacemaker, but is smaller than a AAA battery and less than 10 percent the size of a conventional pacemaker. To implant Nanostim, the surgical team passes a catheter that contains the leadless pacemaker through a small puncture in the groin and then into the femoral vein. Using X-ray images as a guide, we advance the catheter to the right atrium of the heart, through the tricuspid valve, and into the right ventricle. We place the pacemaker and secure it to the wall at the bottom of the right ventricle. After our team tests the pacemaker to ensure it is placed and programmed correctly, we remove the catheter and the pacemaker stays within the right ventricle. We typically implant Nanostim in less than an hour. The risk of infection of the chest incision and dislodged leads are eliminated. If necessary, the pacemaker can be repositioned or removed at a later time. When the pacemaker needs to be replaced, typically after ten years or longer, the procedure is similar to the original implant procedure. Nanostim is the least invasive pacing technology available today. We find patients are more comfortable following Nanostim implantation, and many of the restrictions that were necessary to prevent the leads from moving out of place or becoming damaged are no longer necessary. To refer a patient, contact Linda Mannino, NP, Arrhythmia Center of Excellence, St. John Hospital & Medical Center, (313) 343-3904 or [email protected]. ST. JOHN PROVIDENCE stjohnprovidence.org/updatesandinnovations UPDATES & INNOVATIONS / FALL 2015 15 St. John Providence 28000 Dequindre Warren, MI 48092 stjohnprovidence.org Non-Profit Organization US Postage PAID St. John Health