Author Archives: Carolyn Mogan

PULMONARY ARTERIAL HYPERTENSION EARLY REFERRAL, COMPREHENSIVE CARE ARE KEY

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The Pulmonary Hypertension Program at the University of Michigan Frankel Cardiovascular Center is the largest, most comprehensive pulmonary hypertension center in the state. It is one of the largest centers for chronic thromboembolic disease in the Midwest and one of the few centers in the region to offer pulmonary thromboendarterectomy as a treatment option for chronic thromboembolic pulmonary hypertension.

“We have been in existence since the 1990s, and we are the only center in the state that has been certified by the Pulmonary CIC_Feb_HYPERHypertension Association as a program of comprehensive care. That involved a review process, and we met all the criteria,” said Vallerie McLaughlin, MD,  director of the Pulmonary Hypertension Program. “We have three highly trained physicians and three highly trained clinical nurses that have been doing this for years. I’ve been doing this for 20 years.”

The center has dedicated research and clerical staff, and the program’s clinical team liaises closely with other U-M specialties, including radiology, infectious diseases, rheumatology and pulmonary. The full-service center, which works closely with patient support groups, is very patient-oriented.

Dr. McLaughlin said few clinicians have the expertise needed to treat pulmonary arterial hypertension, a rare disease. “We have everything needed to take care of these patients,” she said. “Pulmonary arterial hypertension is a complex disease, and most clinicians don’t have very much experience with it. Collaborative care with a pulmonary hypertension center—such as ours—and local physicians is in a patient’s best interest. Early referral is key and leads to improved outcomes.”

CAUSES AND SYMPTOMS

A congenital heart defect, heart valve problems or other health issues can trigger pulmonary hypertension (PH). When there are no other underlying heart and lung disease or other illnesses, it is called primary pulmonary hypertension. Primary PH is reported most often in women between ages 21 and 40. Pulmonary hypertension can make everyday activities exhausting and lead to life-threatening heart failure.

Patients with PH may experience:

  • Fatigue
  • Dizziness
  • Shortness of breath

Comprehensive evaluation with right-heart catheterization, a pulmonary function test, a ventilation perfusion lung scan to measure air and blood flow to the lungs, and heart tests can lead to the right diagnosis and treatment options.

“ Collaborative care with a pulmonary hypertension center—such as ours—and local physicians is in a patient’s best interest. Early referral is key and leads to improved outcomes.”

—Vallerie McLaughlin, MD

 

MEET KATIE MEZWA

BACK ON THE FIELD

Katie Mezwa, an active 22-year old, first noticed her symptoms on the lacrosse field. Her journey took many months to understand the causes behind her blurry vision, fatigue and chest pain during routine practice. With shortness of breath as the main symptom, pulmonary hypertension is often misdiagnosed. Katie’s on-field performance was in trouble because of the high blood pressure in the CIC_Feb_HYPER2loop of vessels connecting her heart and lungs.

TREATMENT OPTIONS

With treatment led by Dr. Vallerie McLaughlin, director of the University of Michigan Pulmonary Hypertension Program, Katie manages her pulmonary hypertension with a daily calcium channel blocker to help dilate her blood vessels for easier blood flow.

While a rare disease, researchers are taking a closer look at the molecular basis for PH and testing easier- to-use drugs that can signal vasodilation in the blood vessels in the lungs and improve heart function.

Since the diagnosis, Katie says she’s focusing on living a normal life, which includes playing for the University of Michigan Women’s Club Lacrosse team as the team earned its first national title. Katie earned the Women’s Collegiate Lacrosse Association Division 1 Player of the Year Award.

“To me, that award is a testament to my hard work and dedication, and a great reminder that even a heart condition can’t hold me back,” says the 2015 U-M graduate whose future goals involve improving global health.

Do clothes make the MD? What you wear affects patient perceptions

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What should doctors wear? And how does something as simple as their choice of a suit, white coat, scrubs or slacks influence how patients view them? A new analysis takes a comprehensive look – and finds that the answer isn’t as simple as you might think.

The findings were compiled by a University of Michigan Health System team from a comprehensive international review of studies on physician attire, and other sources. In all, the data they reviewed came from 30 studies involving 11,533 adult patients in 14 countries. Their review has been published in British Medical Journal Open.

In total, 21 of the 30 studies found that patients expressed clear preferences about what they felt doctors should wear, or said that physician attire affected their perceptions of a physician. In 18 of those studies, formal attire or a white coat was the preferred attire.

When the researchers drilled down further, they found that four of the seven studies that involved surgery patients reported that attire choice didn’t matter or that scrubs were preferred. The same was true of four of five studies that involved patients receiving emergency care or intensive care.

One size does not fit all

How you feel about your doctor’s attire can depend greatly on your age and culture, the researchers found. In general, Europeans and Asians of any age, and Americans over age 50, trusted a formally dressed doctor more, while Americans in Generation X and Y tended to accept less-dressy physicians more willingly.

Lead author Christopher Petrilli, M.D., an internal medicine resident at the U-M Health System who worked in the sharp-dressed world of investment banking before switching to medicine, says the study grew out of his conversations with senior physicians, including senior author Vineet Chopra, M.D., MSc, and co-author Sanjay Saint, M.D., MPH.

Chopra, a hospitalist and U-M Medical School assistant professor of general medicine, adds that patient satisfaction now influences how doctors, and hospitals are paid – making the impact of patient perceptions of their doctors’ knowledge, caring, professionalism and trustworthiness all the more important.

And, he says, the findings of the new study suggest that a “one size fits all” approach to policies and guidance for doctors won’t work.

“In order to better tailor physician attire to patient preferences and improve available evidence, we would recommend that healthcare systems capture the ‘voice of the customer’ in individual care locations, such as intensive care units and emergency departments,” he says.

What to wear

The subject of what to wear isn’t covered directly in medical school. Even for physicians in practice at hospitals on the U.S. News & World Report Best Hospitals ranking, specific guidelines are few and far between. Only 5 of those surveyed by the U-M team had official guidance for physicians about attire at all, and most just recommended it be “professional.” The others offered no formal guidance.

Currently, the U-M team is preparing to launch their own international study of the impact of physician clothing choices, under the name “Targeting Attire to Improve Likelihood of Rapport” or TAILOR. They’ll work to quantify how patients’ views of physicians change based on what they’re wearing, and where they’re providing care. The team will also evaluate how attire might affect patients’ trust in what that doctor says or recommends.

Hospitals in three countries have signed on to participate, making it the largest such study of its kind. While pediatric patients and their parents will not be included, the researchers note that this is another area ripe for research.

“Everything is supposed to be evidence-based in medicine,” says Petrilli. “With this review and our new study, we can provide compelling evidence to influence the way physicians dress.”

Posi+ive influence Sacral nerve stimulation offers new hope for children with refractory constipation

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From the day Piper Shumar was born, she suffered from constipation. “Her bowel movements were infrequent, and when she did have one it was softball-sized and hurt her terribly, often causing her to bleed,” says Kimberly Shumar, Piper’s mom.

Year after year, Piper’s constipation issues continued.  She also had a hard time gaining weight.  Even with supplemental nutrition, Piper remained chronically constipated as she turned 4 years old.

“Severe, long-term constipation in children needs to be treated aggressively,” says Dan Teitelbaum, MD, pediatric surgeon and director of the Colorectal Pediatric Surgery Program at C.S. Mott Children’s Hospital.  “Because there can be a number of causes for constipation, accurate diagnosis is the first step in either resolving the issue or ruling out more serious causes.”

A search for a cause

In Piper’s case, her original physicians initially believed she may have Hirschsprung’s disease and recommended an ileostomy.  Piper’s parents sought out a second opinion and were referred to Mott Children’s Hospital.

Dan Teitelbaum, M.D.

Dan Teitelbaum, M.D.

The Shumar family met with Dr. Teitelbaum, who performed additional colon biopsies as part of her evaluation.  Rather than an ileostomy, Dr. Teitelbaum and the colorectal team at Mott recommended an appendicostomy, which would allow Piper’s parents to flush her entire colon to evacuate a bowel movement through a tube in her abdomen once a night.

“Appendicostomy has proven to be effective in select children with intransigent constipation that has failed maximum medical treatment,” says Teitelbaum.  “For many children, this has provided significant relief and a better quality of life.”

Once Piper was placed under anesthesia for the appendicostomy, however, her body relaxed and she had a bowel movement.

“That indicated, to me, that Piper’s problem was actually related to a failure to relax her distal rectum and anal sphincters, says Teitelbaum.  “Based on that information, sacral nerve stimulation was a better alternative for Piper.”

Dr. Teitelbaum left the OR and met with the Shumars to discuss his recommendations with the family, who were pleased to hear that about this new, reversible treatment option.

A pacemaker for the sacral nerve

CIC_Color1Sacral nerve stimulation (SNS) therapy uses a small a neurotransmitter, similar to a pacemaker, implanted under the skin in the upper buttock area. The device sends mild electrical impulses through a lead that is positioned close to the sacral nerve to positively influence the rectal sphincters and pelvic floor muscles.

The Colorectal Pediatric Surgery Program at C.S. Mott Children’s Hospital is one of only a few programs in the country with experience implanting sacral nerve stimulators in pediatric patients.

“Nerve stimulation can be particularly effective for select children with refractory constipation or intractable incontinence caused from injury to the sphincteric complex or congenital problems of the anal canal,” says Teitelbaum.

A two-stage procedure

The procedure is performed in two stages, which allows the team to assess improvement in bowel function during an initial procedure before implanting the subcutaneous device.  Both procedures are performed on an outpatient basis, under general anesthesia by a team of surgeons specially trained in SNS placement.

For most patients, the nerve stimulator can remain in place for three to five years before a new battery has to be replaced.  “At that point, we’ll be able to determine if the stimulation has jump started her system to the point where it’s not necessary anymore,” says Teitelbaum.

In Piper’s case, as soon as the nerve stimulator was implanted and turned on, Piper had a bowel movement. Since the surgery, she’s been having regular bowel movements.

“Piper is like a new kid now. She’s eating well, gaining weight and full of energy,” says Mrs. Shumar. “She calls the stimulator her ‘battery’ and says she loves it.”

C.S. Mott Children’s Hospital Colorectal Pediatric Surgery Program

Sacral nerve stimulation is just one of the cutting-edge treatments offered at Mott for patients who have challenging colorectal disorders. The Colorectal Pediatric Surgery Program team specializes in caring for:

  • Imperforate anus/anorectal malformations
  • Cloacal deformities and cloacal exstrophy
  • Hirschsprung disease
  • Rectal prolapse
  • Familial polyposis
  • Inflammatory bowel disease
  • Anal fissure/fistula-in-ano
  • Bowel management for fecal incontinence and constipation

Mott offers advanced colorectal diagnostics, surgical care and post-operative management of children with these challenging problems. The faculty is committed to incorporating new evidence-based surgical and medical techniques and research discoveries. Unlike many pediatric programs that treat just the disease, Mott provides lifelong support and follow-up care for families of children with colorectal disorders.

Learn more about the Colorectal Pediatric Surgery Program at www.mottchildren.org/colorectal.

Breathing life into fragile lungs Ex vivo lung perfusion makes more lungs available for transplant

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Kyle Clark, 25, of Imlay City was a very sick young man when he was admitted to U-M in February. Oxygen therapy was no longer sufficient to keep the effects of cystic fibrosis at bay, so physicians at the U-M Transplant Center moved him along an expedited pathway to join a groundbreaking clinical trial.

The University of Michigan and Gift of Life Michigan, in collaboration with Henry Ford and Spectrum health systems, are the only study

If only 25 percent of the currently unusable lungs were salvaged, it would double the number of available lungs for transplantation

If only 25 percent of the currently unusable lungs were salvaged, it would double the number of available lungs for transplantation

participants in Michigan. The study, which is on the forefront of science and technology, uses ex vivo lung perfusion to optimize lungs for transplantation that might otherwise have been deemed unusable.

Ex vivo perfusion is based on the heart-lung support technology known as extracorporeal membrane oxygenation, or ECMO, which was pioneered at the University of Michigan by Robert Bartlett, M.D., now a professor emeritus of Surgery.

A lung incubator

The study is evaluating the revolutionary XVIVO Perfusion System from Sweden, which has the ability to warm lungs to normal temperature, re-inflate them and allow physicians to recondition and evaluate them for transplant. The environment permits the potential recovery of transiently damaged lungs in a short period of time.

“Think of the XVIVO as an incubator. Right now, our transplant team has a window of about four hours to determine whether lungs are optimized in the XVIVO and are going to be suitable for transplant. But the window of recovery is brief and the transplant must take place soon after. Things moved rapidly for Kyle,” says Rishi Reddy, M.D., one of the U-M transplant surgeons who performed Clark’s transplant. “In the future, I expect improvements will give us more time to assess donated lungs. Perhaps we could have as long as 24 hours for lungs to be reconditioned and implanted.”

In Clark’s case, the donated lungs would not have been suitable but for the recovery process they went through prior to implantation, and he would have remained on the transplant waiting list, losing more of his ability to breathe as each day passed. Instead, he became the first Michigan resident to receive lungs reconditioned in the XVIVO device.

Salvaging lungs to save lives

“Historically, less than 20 percent of organ donors actually have their lungs used to save a life. Often the nature of a donor’s death traumatizes the lungs, even when other organs are usable. For example, lungs may be bruised or punctured from the trauma of an automobile accident,” says Reddy. “But others are unusable because they are transiently injured. Some of these can benefit from the special incubation and reconditioning in the XVIVO device. This means that in the future, there will be more lungs available for transplant, and people on the list could have shorter wait times.”

Reddy anticipates that even if only 25 percent of the currently unusable lungs were salvaged, it would double the number of available lungs for transplantation. And with quicker access to transplantation, fewer people will die while waiting.

Ex vivo perfusion is one of three research approaches to the shortage of donor lungs, and the first to come to market. Organogenesis and stem cell transplants show promise in replacing or repairing damaged lungs but are not yet ready for clinical study.

Collaborating to raise hope

Collaborating to raise hope (sidebar): Transplants using the XVIVO Perfusion System from Sweden currently take place within the framework of an interventional clinical trial studying the safety of recovering marginal donor lungs for implantation. The University of Michigan, Gift of Life Michigan, who purchased the device, and Henry Ford and Spectrum health systems are collaborating in the clinical trial.

The device resides at U-M where its five lung transplant surgeons use the XVIVO device to provide services to the lung transplant programs at Henry Ford and Spectrum, as well as their own. The U-M Transplant Center ™ is the largest and most experienced in Michigan, and one of the largest in the nation. The collaboration among the three transplant centers is unique in Michigan and was done to bring the hope of transplantation to more patients needing this lifesaving surgery.

Get more information about the XVIVO trial at umclinicalstudies.org or visit clinicaltrials.gov and enter identifier: NCT01365429

Head Start Fetal myelomeningocele repair prevents spinal cord damage and improves neurologic function

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CIC_heads1It was a day Kasey Hilton had been anticipating from the beginning of her pregnancy – finding out whether she was having a boy or girl. But the ultrasound appointment in June, 2014 brought news she and her husband Mike weren’t ever expecting to hear. They were having a baby boy, but he had a serious spinal cord defect called myelomeningocele that is associated with lifelong disabilities.

There was, however, hopeful news. University of Michigan’s C.S. Mott Children’s Hospital had recently become the only hospital in the region and among just over a dozen in the country to offer fetal surgery to correct the defect months before birth. The procedure prevents further damage to the spinal cord and improves neurologic function.

The Hiltons spent the day meeting with many experts from the Fetal Diagnosis & Treatment Center at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital.  After extensive testing, doctors determined that Kasey and the baby were potential candidates for the procedure. The Hiltons then underwent multi-disciplinary counseling by the team to understand the relative maternal and fetal risks and benefits.

It takes a team

“A prenatal diagnosis of myelomeningocele can be overwhelming for families, but this new procedure offers hope for better outcomes,” says Marcie Treadwell, M.D., director of U-M’s Fetal Diagnostic Center.

“Although not a cure, fetal surgery prevents ongoing damage to the spinal cord and is associated with improved neurologic outcomes,” says Cormac Maher, M.D., associate professor of pediatric neurosurgery.

Last July, when Carter was only 23.5 weeks gestation, Kasey underwent open fetal surgery with the hope of improving her baby’s outcome.  This procedure required an experienced multi-disciplinary team working seamlessly together.  Maternal anesthesia was provided by Dr. Baskar Rajala, pediatric anesthesia by Dr. Paul Reynolds, and fetal monitoring by Drs. Sarah Gelehrter and Rebecca Jane Vartanian. Five surgeons were involved in the procedure – Treadwell, Maher, pediatric surgeon George Mychaliska, M.D. and maternal fetal medicine specialists Deborah Berman, M.D., and Clark Nugent, M.D.

The doctors performed open fetal surgery which involved deep maternal anesthesia, hemostatic hysterotomy, extensive maternal and fetal monitoring and partial exposure of the fetus. Once they had access to the one-pound fetus, Dr. Maher performed the delicate, 30-minute operation to repair his spinal canal and cover the defect with skin.  The uterus was closed using a specialized technique to incorporate the membranes and ensure a watertight seal.

Hilton was closely monitored in the hospital by the maternal fetal medicine team and then sent home on bed rest.  She underwent serial ultrasound examinations and for signs of preterm labor.

At 34 weeks, Carter Hilton was born via C-section. Although Carter did require a ventriculoperitoneal shunt, he is currently six months old and doing well.

Innovative and promising

“Fetal surgery for myelomeningocele is innovative and promising,” says Mychaliska, director of the Fetal Diagnosis and Treatment Center. CIC_heads2“Although fetal surgery improved outcomes, children with myelomeningocele still require long-term care. In addition, the potential fetal benefits must be weighed with an understanding of the potential maternal and fetal risks.”

For nearly a decade, U-M doctors have been working together to develop the Fetal Diagnosis and Treatment Center which provides comprehensive prenatal diagnosis and cutting edge fetal surgery for carefully selected patients.  “We are fortunate to have a talented and experienced team dedicated to our maternal and fetal patients,” says  Mychaliska.

“The team carefully explained to us the risks involved for both me and my unborn son but we did not hesitate to say yes in light of the potential to improve his quality of life,” Kasey Hilton says. “I had concerns, as anyone would, but knew I was in good hands.

“We’ll have to watch Carter for various milestones in his life and we won’t know if he will have challenges with things like walking or with his bowels and bladder until he’s old enough to walk and potty train. For now, he’s doing great and we are grateful to the entire fetal team at U-M for a procedure that could help give him a better future.”

The MOMs trial

The landmark randomized prospective clinical trial comparing prenatal versus postnatal repair of myelomeningocele, known as the MOMS trial, closed early due to efficacy, and the results were published in the New England Journal of Medicine. By 12 months, children who had fetal surgery had a decreased need for shunting and less hindbrain herniation.  At 30 months of age, those who received fetal surgery also scored better on mental and motor function tests and were more likely to walk independently. However, fetal surgery was also associated with an increased risk of preterm delivery and uterine dehiscence at delivery.

Inclusion Criteria

  • Mothers ≥ 18 years of age
  • T1—S1 with hindbrain herniation
  • Normal fetal karyotype
  • Gestational age between 19 to 25 weeks

Exclusion Criteria

  • Fetal anomaly unrelated to myelomeningocele
  • History of spontaneous preterm birth
  • Maternal BMI > 35
  • Maternal co-morbidities
  • Inability to comply with follow-up

Michigan’s Comprehensive Stroke Center Helping patients achieve best level of function

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The most advanced stroke treatments and equipment in the world won’t make a difference in an environment that can’t support their use.

Fortunately, the University of Michigan’s Comprehensive Stroke Center can meet stroke head on. Accredited by the Joint Commission, all physicians are board certified. And as they offer care for patients—from straightforward conditions through the most complex cases—they have the latest technologies readily available.

“Our teams of physicians, nurses and therapists are set up to ensure all of our patients receive the highest level of care, from their emergency department (ED) stay until their discharge,” says neurologist Eric E. Adelman, M.D. Adelman co-leads the Center with neurosurgeon Aditya S. Pandey, M.D., and emergency medicine physician William Meurer, M.D.

“We have a strong focus on quality improvement and continually work to improve the care we provide.” The Center treats patients before, during and after stroke, through preventive, emergent and rehabilitative care, and can accept new patients at any point throughout the care continuum.

The Team
Eric Adelman, M.D.

Eric Adelman, M.D.

Patients at U-M are treated by a multidisciplinary team of emergency medicine, neurology, neurosurgery and neurointerventional radiology physicians who are specially trained in stroke care. Vascular surgeons, cardiologists, internal medicine and physical medicine and rehabilitation physicians are also part of the care team.

The Center always keeps in mind that just as no two strokes are the same, neither are any two patients the same.

“Our goal is to design a team specific to the patient and disease,” says Aditya Pandey, M.D.

Cerebral aneurysms and AVMs can also cause significant neurological disability and even death, and U-M has a multidisciplinary approach to treating such individuals with such difficult conditions as well.

Aditya S. Pandey, M.D.

Aditya S. Pandey, M.D.

“Our radiologists and neurosurgeons use the latest techniques in providing cutting-edge treatments in the safest manner. We have three dual trained cerebrovascular neurosurgeons who treat diseases with both minimally invasive endovascular techniques as well as open microsurgery techniques,” Pandey says.

After any type of stroke procedure, patients go to either the Stroke Unit or the Neuro ICU. “Our state-of-the-art Stroke Unit and Neuro ICU ensure that patients can be safely monitored by nursing staff and have ready access to  rehabilitation,” Adelman says.

Clot-busting Stent Retrievers

In one of Michigan’s unique surgical rooms, a CT scan of the head can be performed in the same room where doctors can remove clots from vessels or repair brain aneurysms, saving critical time for the stroke patient.

“Here, we are able to use neurointerventional radiology to enable endovascular image-guided treatment of brain aneurysms, brain bleeds and opening of blocked brain vessels,” says Neeraj Chaudhary, M.D., MRCS, FRCR. “Our endovascular practitioners are extremely well-trained in the use of all the state-of-the-art medical devices. And their expertise is supported by a robust setup of regular monitoring of clinical outcomes to ensure the best for our patients.”

Among the newest generation devices are stent retrievers. They resemble the wire stents often used to keep coronary arteries open but function more like a trap. When a catheter containing a collapsed stent retriever reaches a clot blocking a cerebral artery, the stent moves out of the catheter, unfolds to form a 3-D mesh tube, ensnares the clot and retracts back into the catheter with its catch. Surgeons then thread the catheter with the clot back out of the body.

In the meantime, the artery is cleared and blood flows back into the brain, replenishing its vital supply of oxygen and glucose.

Neurosurgical Intensive Care Unit (NICU)

CIC_stroke3The Neuro ICU is a 15-bed unit that cares for critically ill neurosurgery and neurology patients, including stroke patients. The unit is led by neurointensivist Venkatakrishna Rajajee, MBBS, and staffed by four board-certified neurointensivists, which is relatively rare.

“We add value in different ways,” says Rajajee. “For the neurosurgery patient, the Neuro ICU allows particularly high-risk, complicated procedures to be performed. Yes, you know you can provide treatment and surgery, but you want to be certain that there is the ability to provide care afterwards if there are complications. You want the ability to monitor the patient extremely closely afterwards. You can lose all the benefits from the surgery if you don’t have the ability to provide the care afterwards.”

Stroke Rehabilitation—Individualized Treatment Plans

Rehabilitation Physician Edward S. Claflin, M.D., leads the U-M Acute Stroke Rehabilitation Program for patients who have significant disabilities because of stroke.

Once again, state-of-the-art equipment and technologies—such as the Lokomat robotic exoskeleton, BioEx gait training with biofeedback, Bioness technologies, Saebo hand and foot functional tone management, graded UE biking, and neuromuscular and functional electric stimulation—are backed up by the knowledge and expertise of a truly interdisciplinary and collaborative team.

Their team of experts includes a physical medicine and rehabilitation physician (a physiatrist), physical therapists, occupational therapists, speech language pathologists, neuropsychologists, rehab engineers, exercise technicians/personal trainers, orthotists/prothetists and a case manager.

“The medical or surgical team asks for rehabilitation assessments by therapists as soon as it is deemed safe—usually within hours of a patient’s admission. These therapists will continue to see patients in the hospital until they move to the next level of rehab,” says Claflin. After assessment, the team develops specific rehab goals and a timeline for transitioning to another rehab setting or back home. The team even develops home exercise plans so that patients can maintain their level of function.

“Our goal is to help patients achieve their best level of function after stroke,” Claflin says.

Working Together

“A truly comprehensive stroke care setup cannot function unless there is genuine collaboration among its different components,” says Chaudhary. “Here at the University of Michigan, all the components of such a comprehensive stroke center work in perfect harmony.”

“We appreciate the privilege of treating all of these patients and appreciate each referring physician’s important contribution in allowing us these opportunities,” Pandey says.

New Hope for Multiple Sclerosis

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CIC_MS1Since the University of Michigan created its Multiple Sclerosis Center in 2007, Michigan has been fighting a good fight against MS. Under the direction of Benjamin Segal, M.D., the center has grown from 400 patients and one physician to 3,000 patients and six specialty physicians. This growth represents an all-out war against MS, with clinical, translational and clinical research arms. The strategy is working so well that the center was designated a Center of Excellence for Comprehensive MS Care by the National Multiple Sclerosis Society (NMSS).

The center takes a multidisciplinary approach, collaborating with physical medicine, pain specialists, urologists and neurologists. “All in the interest of helping our patients in the most expert way,” says Segal.

In addition to providing patient care in the outpatient clinic, the center is conducting several clinical trials for both relapsing remitting and secondary progressive MS to further the treatment options for the disease.

Siponimod Phase III – Largest Trial in the World

Dr. Yang Mao-Draayer is principal investigator and Segal is co-investigator on a Phase III trial to see how the drug siponimod impacts the immune system in patients with secondary progressive MS. Siponimod is a variation of fingolimod, a drug that is used in relapsed or remitting MS patients but was designed to have fewer side effects.

The study involves more than 300 centers around the world, is the largest secondary progressive MS trial ever conducted and includes nearly 1,600 subjects worldwide. “Our study is the first in-depth immunological study of its kind for MS and involves a unique collaboration among 19 US academic centers, Novartis and the National Institutes of Health,” says Yang.

Surprising Connections Between Sleep Disorders and MS

Dr. Tiffany J. Braley is interested in the causes of fatigue in MS and how to better treat it.

“It turns out that a good portion of people with MS have a sleep disorder that is contributing to their fatigue,” says Braley.

Obstructive sleep apnea (OSA) is underdiagnosed in MS patients, and Braley has found that such sleep disorders are more common in patients with MS than the general population. She is studying whether the effects of the disease itself as well as the treatments given to patients to decrease relapse rates impact patients’ sleep hygiene and put them at a higher risk for OSA.

She has started an MS/sleep and fatigue subspecialty clinic—the first of its kind in the country—where she and Dr. Ronald Chervin, director of the U-M Sleep Medicine Division, evaluate and treat MS patients with severe fatigue, tiredness and sleep disorders.

“In addition, I am looking at whether or not some medications that are used to treat MS may help alleviate sleep apnea in the general population,” Braley says. “We continue to find connections between the two conditions.”

Extracorporeal Photophereresis – Enrolling for Trial Now
“ Compared to other MS treatments, it is relatively low risk. If this works, it will be a huge advancement in the management of progressive MS.” —Benja min M. Segal , M.D., Director, U-M Multiple Sclerosis Center

“ Compared to other
MS treatments, it
is relatively low
risk. If this works,
it will be a huge
advancement in
the management of
progressive MS.”
—Benjamin M. Segal , M.D., Director,
U-M Multiple Sclerosis Center

“I am one of the people who believes inflammation plays a role during all stages of MS. However, every patient is unique,” says Segal. “The type of inflammation that causes damage may vary between individuals. This may be why there is no immunoregulatory drug that is effective across all patient subsets.”

There are now 13 FDA-approved medications that decrease risk of clinical exacerbation in patients in the relapsing-remitting stage of MS. “However, we do not have a cure, and there are no highly effective medications that slow, let alone reverse, the accumulation of disability in patients in the progressive stages of MS,” he says.

So Segal has tried a different approach, concentrating on the idea of combating inflammation in progressive MS, but coming at it from a different direction. “One of my colleagues, Dr. Daniel Couriel, chief of the Bone Marrow Transplant unit, uses a technique called extracorporeal photopheresis (ECP) to treat graft versus host disease—an inflammatory disease of multiple organs that occurs in some patients following bone marrow transplantation. In a way, it’s like an autoimmune disease,” he says.

ECP is a relatively safe procedure involving removal of some white blood cells from a patient, exposing those cells to UV light in the presence of a photosensitizing agent and then reinfusing those cells.

Segal and Couriel used ECP on a father of two with progressive MS who had not responded well to other treatments, even chemotherapy.

“He went from spending most of the day in a motorized scooter to walking with a cane. A second patient could stand in the shower for the first time in years. A third did not make gains but she did not deteriorate either.”

“As far as I know, we’re the only site in the world that’s doing this procedure in this way to treat progressive MS,” Segal says.

“Compared to other MS treatments, it is relatively low risk. And if this works, it will be a huge advancement in the management of progressive MS,” Segal says.

FOR REFERRING PHYSICIANS
ECP – Enrolling for Trial Now

Patients with secondary progressive MS not currently treated with disease modifying therapies may be eligible for the ECP trial. Trial candidates should have experienced disability accumulation over the past 1-2 years. Please contact Amanda Rasnake, clinical trial coordinator, at (734) 232-2452 if you would like to refer a patient to the trial.

MS/OSA Trial

This clinical trial will evaluate the effects of Positive Airway Pressure (PAP) on cognitive function in multiple sclerosis patients who have obstructive sleep apnea. MS patients who have concerns about their cognitive function or who are at risk for obstructive sleep apnea may be eligible.

Please contact study coordinator Nancy Kessler (734) 647-9067, nrypkows@med.umich.edu, if you would like to refer a patient to this trial.

 

Spine Surgery Program

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In the world of medicine, the words “minimally invasive” and “spine surgery” don’t usually go together. But for the past decade, the University of Michigan Spine Surgery Program has moved many spine surgeries into the minimally invasive realm—with great success. In fact, U-M is the first program in the state completely dedicated to the advancement of minimally invasive spine surgery.

“A lot of the minimally invasive spine procedures started with ‘basic’ spine procedures such as discectomies, laminectomies and level-one lumbar fusions of the spine,” says Paul Park, M.D., associate professor of neurosurgery and of orthopaedic surgery. The program soon realized success in outcomes as good as or better than the traditional surgery. The surgeries also had the added benefits of smaller incisions, less tissue injury and blood loss during surgery, less postoperative pain and reduced hospital length of stay.

SPINE_SURGERYNow, discectomies and laminectomies are outpatient procedures, and the hospital length of stay for fusion surgery is much shorter.

“It’s a constantly evolving field because once we saw success for these more basic spinal surgeries, we started applying them to more complex situations such as tumor resections and deformity.” Although not all complex cases are amenable to minimally invasive surgery, each patient is evaluated for a less invasive approach with the ultimate goal of achieving best possible outcomes.

WHO WE TREAT
Today, the U-M Spine Surgery Program provides state-of-the-art services to individuals whose spinal disorders affect their health and productivity, and whose disorders require surgical intervention. Patients referred to the spine surgery program may suffer from pain and/or neurological deficits due to degenerative spinal disease, scoliosis, spinal tumors, spine cancer, spine infections or traumatic injury.

“We offer treatment options for the whole spectrum of spinal pathologies,” Park says.

NEW TECHNOLOGIES
Minimally invasive spine surgery is an area in which new technologies matter greatly. Along with the latest state-of-the-art computer-assisted image guidance and operating microscopes, U-M has technologies and resources that few other hospitals have. For example, the University of Michigan was the first hospital in the state to use the O-ARM Multidimensional Imaging System.

Neurosurgeons have the option to use the O-ARM to view patient anatomy in the operative position, monitor the status of the surgery and verify surgical changes with real-time 3-D volumetric images, all before the patient leaves the surgical suite.

“We’re always investing in or trialing new technologies such as the O-ARM for increased patient safety and better outcomes,” Park says. “We also use new technologies in conjunction with newer techniques for improved outcomes as well, such as using the O-ARM for image guidance for lateral interbody fusion, which is an alternative minimally invasive approach for fusion of the thoracic and lumbar spine.”

For Referring Physicians
Dr. Park suggests that it is appropriate to refer patients who have failed nonoperative management, for example, if they have had physical therapy and injections and are still having issues (the most common of which are back pain or leg pain). In patients with neurological deficits such as weakness, referral should be done urgently.

“If you have a patient with a weak foot, for example, I wouldn’t try nonoperative measures; they need more of an urgent surgical evaluation first,” Park says. “But if it’s typically a pain issue, a trial of nonoperative management is typically recommended.”

Clinical Trials
Multiple clinical trials are ongoing or planned at the University of Michigan Spine Program involving treatments for a variety of spinal pathologies including degenerative disease, infection, trauma and deformity.

One example is our participation in a Phase 2 multicenter clinical trial to study stem cell transplantation in cervical spinal cord injury,
sponsored by StemCells, Inc.

For more information: contact Clinical Trial Coordinator Karen Frisch, 734-936-7469. kfrisch@med.umich.edu.

 

Fall prevention research for Parkinson’s Disease

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Every year, up to 70% of people with Parkinson’s Disease (PD) will fall, often leading to serious medical and social issues. The National Institute of Neurological Diseases and Stroke has awarded the Michigan Department of Neurology a five-year, $11.5 million grant to establish the Morris K. Udall Center of Excellence for Parkinson’s Disease Research focused on developing a treatment to prevent falls.

Clinical Trial Opportunities
Importantly, much of the Center’s work is clinical research on patients with earlier stages of Parkinson’s before falls emerge, but it is hoped that the novel therapeutic approach will ultimately help decrease falls in those experiencing them. Involvement of adequate numbers of patients is critical for success.

fall_preventThose interested in participating can register to be contacted at www.clinicalstudies.org (search for “Parkinson’s disease” and click on study titled “Cholinergic Mechanisms of Gait Dysfunction in Parkinson’s Disease”).

The Center conducts experimental, computational and human research to further investigate the possibility that the degeneration of cholinergic neurons is an important cause of gait dysfunction in Parkinson’s Disease. The Center is both testing this possibility—based  upon considerable earlier findings—and working to develop a novel treatment strategy targeted at cholinergic neurotransmission.

With this grant, Michigan becomes one of only nine Morris K. Udall Centers of Excellence in Parkinson’s Disease in the United States.

For more information, visit udallpd.umich.edu.

 

MEET Elizabeth Scheffler

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Elizabeth

Retired teacher Elizabeth Scheffler had been dealing with some form of essential tremor (ET) for 10 to 15 years. Finally, she says, “It had become increasingly worse, to the extent that I had very little, if any, fine motor control and progressively compromised gross motor skills.”

The tremor was bilateral, and she also had a head and voice tremor. “It was not possible to carry a cup of coffee without spilling, eat a sandwich without shaking it apart or feed my then-infant grandson,” Scheffler remembers. She tried three or four medications, which made little or no impact on the tremors. “One neurologist in Colorado was even treating me for Parkinson’s, which it turns out I do not have.”

One day, Scheffler saw a television program about a man with essential tremor who underwent deep brain stimulation (DBS), a pacemaker-like procedure for the brain. The results were remarkable.

After Internet research, she met with Dr. Kelvin Chou, co-director of the University of Michigan Movement Disorders Clinic, who confirmed that she was a good candidate for DBS.

Like all DBS candidates, Scheffler underwent speech and neuropsychological testing before being accepted for surgery. “Dr. Parag Patil, the DBS neurosurgeon, also met with me, to explain the surgery,” she says. “Although initially it was a difficult decision and I was apprehensive, the staff was very reassuring and gave me success rates, number of operations completed, etc.  They allayed my anxiety by answering all my questions in such a caring way that I wasn’t even really nervous before the surgery.”

DBS is a two-part surgery. During the first part, in which the stimulator is placed in the brain, she says, “The neurosurgical staff told me exactly what to do, explained each step of the surgery and the result to expect. They also conducted speech evaluations throughout the surgery to

Scheffler received consultation from Laura Zeitlin, MSW, to understand how to control the batteries implanted in her chest that generate electrical pulses to her brain.

Scheffler received consultation
from Laura Zeitlin, MSW, to
understand how to control the
batteries implanted in her chest
that generate electrical pulses to
her brain.

ensure speech centers would not be affected.”

The second surgery (two weeks later) implanted the battery pack into her chest. “Although the first surgery made for a long day, I experienced no pain and required none of the prescribed drugs. The second surgery was a breeze.

“I now have full control in my dominant hand and my head tremor is gone,” Scheffler says. “Now I fully enjoy my retirement, volunteering as treasurer of a non-profit agency, playing bridge, doing floral arranging, yoga and golf. I can even do some photography and enjoy my electronic devices.

“I heartily encourage anyone with this condition to further explore whether they are a good candidate for DBS. It has changed my life in such positive ways.”