Outstanding treatment OptiOns For advanced and · OptiOns For advanced and recurrent colon and...

Outstanding treatment

OptiOns For advanced and recurrent colon

and rectal cancer PAGE 4

REFERRING PHYSICIAN NEWSLETTER SPRING 2010

Working together is

Good Medicine

PLUS Tufts Medical Center.tv 3 Dermatological Research 8 New LVAD Study 10 Diabetes Q&A 14

3 8 10 14

2 Tufts Medical Center

Dear Physicians,

In my last Good Medicine letter to you, I mentioned that my phone line had been hot

with physician groups and hospitals calling about potential partnerships with Tufts

Medical Center. At the time, I couldn’t tell you who had been calling, but I did tell you why I thought they

were calling. Today, I am pleased that I can tell you more on both these fronts.

First, about our new affiliates: We are extremely excited to have signed affiliations with Signature Health-

care Brockton Hospital and Jordan Hospital. The Highland IPA of Winchester Hospital has joined our com-

munity physician network — New England Quality Care Alliance. Tufts Medical Center is now the preferred

tertiary hospital for these excellent community hospitals and physicians. Together, our hospitals and

physicians are collaborating to make sure appropriate care stays in the community, and when needed,

tertiary care is accessible and well-coordinated. Our physicians are getting to know each other and working

diligently to provide high-quality and convenient services for patients. At a recent celebration with the High-

land IPA, I heard several physicians comment on the energy in the room and the ease with which Highland

physicians and Tufts MC physicians were already communicating. We are enjoying the process of launching

these affiliations and are focused on the extensive possibilities they present. Stay tuned: there’s more in

the pipeline to come!

Next, why we are a great partner: In addition to the collaborative spirit I just mentioned, the evidence is in

that Tufts Medical Center is a high quality, efficient academic medical center. In a recent unblinded report

from the Massachusetts Attorney General’s Office, it was shown that Tufts Medical Center is by far the

most affordable tertiary option in Boston and that we have the highest Case Mix Index among the local

AMCs. This should be important to us all, and especially meaningful for organizations forming ACOs and

operating under AQC arrangements. Health care reform is happening; we are ready. Are you? We’d love

to talk to you about developing a strong partnership with us.

Interested? Call or email me. 617-636-9589, [email protected].

All the best,

Ellen Zane

President and CEO

Tufts Medical Center

A letter from ellen Zane

Cover photo: multiple polyps seen in the sigmoid colon

Good Medicine 3

h ave you ever referred a patient to Tufts Medical Center and wished the patient could “get to know” the physician before coming here?

Have you ever wished a patient could access easy to understand information concerning their diagnosis?

If so, we have a great new resource for you and your patients: www.TuftsMedicalCenter.tv.

This new and exciting website features videos of physicians dis-cussing health topics and medical information. The three to five minute videos provide an overview of different diseases and condi-tions as well as cover the symptoms and possible treatment op-tions. They are an excellent resource for your patients and for their family and friends.

TuftsMedicalCenter.TV!

Tufts Medical Center has been letting patients know about this site through a marketing campaign on the airwaves and on the web. We also hope you will share the web address with them when you make a referral to Tufts Medical Center or would like to share infor-mation about a condition with them.

Patients may see and hear ads promoting the site on local radio stations, on popular web sites including Boston.com and theboston-channel.com, and on television (WBZ-TV Channel 4).

Videos address clinical topics including atrial fibrillation, pediatric reflux disease, colon cancer, and spinal stenosis, just to name a few.

We hope to add more videos in the future; if you have a topic that you think would be particularly helpful to your patients, log onto the site and submit the idea. We would love to have your feedback. o

Direct your patients to our new website for timely information about diseases, signs and symptoms and treatment options.

www.tuftsmedicalcenter.tv


Bruce Orkin, MD in the OR

Outstanding treatment

OptiOnsFor advanced and

recurrent colon and rectal cancer

DOCTOR’S NOTES

to refer a patient to the Division of Colon and rectal Surgery, call 617-636-6190.

Good Medicine 5

When Bruce A. orkin, mD

joined tufts medical

Center as Chief of Colon

and rectal Surgery in may of 2009,

the business plan forecasted that

it would take two years before the

new division needed a second

full-time surgeon. today, however,

orkin is recruiting another surgeon

— 14 months ahead of schedule —

to help handle the volume.Why so much demand, so fast?

Combine Orkin’s nationally renowned surgical expertise with the multidisci-plinary talent already in place at Tufts Medical Center, and word is out that this is the place to turn for an exceptional depth and breadth of sophisticated treatment resources for colon and rectal cancers — the third most common cancer diagnosed in the United States.

For patients with advanced and recurrent colon and rectal cancers, in particular, the Tufts Medical Center Division of Colon and Rectal Surgery offers an array of cutting-edge treatment options that offer hope for prolonged survival and improved quality of life.

One such treatment option is transa-nal endoscopic microsurgery (TEM), a minimally invasive technique for the local excision of small rectal tumors or some large polyps. The surgeon can operate on lesions or polyps in the mid and upper rectum without making an incision through the abdomen, using specially designed instruments that enable the procedure to be performed through the anus and in the rectum.

Orkin learned the procedure from the man who pioneered it, German surgeon Gerhard F. Buess, MD, and was one of the first surgeons to perform TEM in the United States starting in the early 1990s. To date, Orkin has performed more than 250 TEM procedures, one of the largest individual case volumes in the world.

And he is one of only a handful of qualified TEM surgeons in the region.

“While TEM is used primarily for early cancers, it does have a role in advanced cancer,” Orkin notes. “In advanced rectal cancer, we see patients with metastatic disease who also have a rectal primary lesion. Sometimes the rectal primary is not that big, but it’s bleeding and the patient is experiencing a lot of pain.”

“With TEM, we often can do a pallia-tive resection and remove the primary lesion for symptom control and to improve the patient’s quality of life,” he continues. “TEM is nice because it’s quick, easy, low risk, and there’s a short recovery, so the patient can move on to treatment for metastatic disease without losing much time.”

In fact, when compared with conven-tional trans-abdominal operations for rectal tumor removal — such as low anterior resection or abdominal perineal resection, which usually require a seven- to 10-day hospital stay and a six-week recovery — TEM patients can go home the same day and recover in about two weeks.

For colon cancer that has advanced locally, Orkin has other techniques in his surgical arsenal.

“Advanced local disease in the colon might present with a blockage, or the tumor invading through the bowel wall to adjacent structures such as the abdominal wall, liver, spleen, pancreas, stomach, duodenum, small bowel, bladder or uterus,” he explains. “We can still get good cure rates if we’re aggressive and do an en-bloc resection to get all the way around it. It can be a daunting task, since it involves removing the organ being invaded.”

“But while it’s a big operation, the benefits are big, too,” he adds. “Some patients can be treated for cure, while others get good palliation.”

Orkin notes that sometimes he leaves clips marking the margins where some cancer may be left to help guide radia-

BRuCE ORkiN, MDChief, Division of Colon and Rectal Surgery

medical SchoolUniversity of Minnesota

General Surgery residencyMayo Clinic

Colorectal Surgery residencyCleveland Clinic

GI research fellowshipMayo Clinic

Prior PracticeDirector, Division of Colon and Rectal Surgery, The George Washington University

Board CertificationsGeneral Surgery, Colon and Rectal Surgery

Clinical SpecialtiesCrohn’s disease, ulcerative colitis, colon, rectal and anal cancer, diver-ticular disease, laparoscopic colon and rectal surgery, complications of colostomies and ileostomies, transanal endoscopic microsurgery for rectal polyps and cancers, anorectal disorders

research InterestsComplications of ostomies, inflam-matory bowel disease, pathogenesis of colorectal and anal cancer, treatment of early rectal cancer

continued on next page


tion therapy. He also uses pelvic slings made of Vicryl mesh.

“The sling acts as a hammock, holding the small intestine up and out of the pelvis so we can give radiation after surgery without injuring the small bowel,” he says.

Orkin explains that laparoscopic colorectal surgery also is an option for appropriately selected patients with advanced local disease.

“I’ve probably done over 500 laparo-scopic colon resections for a variety of reasons, cancers among them,” he says. In fact, he is among the first group of surgeons to develop the technique, starting in 1990. He also is beginning to use the da Vinci robot for pelvic resection for rectal cancer.”

“If we can’t resect, we then commonly use various forms of radiation — exter-nal beam and brachytherapy — and advanced chemotherapy,” Orkin points out, with a nod to the multidisciplinary resources that make cancer care at Tufts Medical Center so comprehensive.

Douglas Janowski, a gastroenterolo-gist and Director of the Endoscopy Center at Tufts Medical Center, says that Orkin and his team are great partners in the care of patients. “Once I have diagnosed a colon or rectal cancer, I work to guide my patient through what can be a frightening and confusing experience. It is comforting and reassur-ing both for me and for my patient to have an individual like Bruce to partner with for the treatment of this cancer. With Bruce, Tufts Medical Center now has a world-class colorectal surgeon whose expertise spans across all of the available surgical techniques and technologies and who simultaneously provides a personal touch that com-pletes the healing process for our patients,” says Janowski.

For metastatic colorectal disease, which most often spreads to the liver and lungs, Orkin cites a range of treat-ment options including resection, radiofrequency (RF) ablation and intrahepatic chemotherapy for liver metastases, and a combination of

resection, directed chemo and radiation therapy, and RF ablation for lung metastases. Thoracic surgeons Laurence Brinckerhoff, MD and Yaron Perry, MD provide minimally invasive, video-as-sisted techniques for lung surgery.

When colorectal cancer spreads to the surface of organs inside the abdominal cavity (peritoneal carcinomatosis), Tufts Medical Center is one of only a few hospitals nationwide to offer a treatment called HIPEC, or hyperther-mic intraperitoneal chemotherapy. HIPEC is also used in treating cancer of the appendix, ovarian cancer, peritoneal mesothelioma and gastric cancers.

“It’s a two-part procedure,” explains Martin D. Goodman, MD, who heads the Peritoneal Surface Malignancy program in the Surgical Oncology division at Tufts Medical Center. “First, we go in and debulk the tumor, surgi-cally removing all the disease that’s visible. Then we circulate about two

liters of heated fluid throughout the peritoneal cavity and add high doses of chemotherapy to it. The heat and the chemo work synergistically to destroy any microscopic cancer cells that remain after surgery.”

“With HIPEC we can administer a higher dose of chemotherapy that comes into direct contact with cancer cells,” he continues. “This dose would be too high for patients to tolerate if it were delivered intravenously.”

“For patients diagnosed with perito-neal carcinomatosis, this treatment can prolong survival and give them a good quality of life,” Goodman adds.

Robert E. Martell, MD is the go-to resource when systemic chemotherapy is indicated for advanced colon and rectal cancer. A respected medical oncologist specializing in gastrointesti-nal cancer, he was recently recruited from the pharmaceutical industry to be the physician leader of Tufts Medical Center’s Experimental Therapeutics program. Martell is double board-certi-fied in internal medicine and medical oncology with a PhD in pharmacology. He began his career in academia then transitioned to private industry, where he led clinical development of several new cancer-fighting compounds.

“In addition to my focus on GI oncology and experimental therapeutics here at Tufts Medical Center, I’m developing a series of early-phase clinical studies that will help advance medicine for patients with advanced cancers,” Martell says. “We’re not only giving the best care available, but also developing novel treatments to improve that care. For patients who have ex-hausted standard treatment options, we can offer other options that may provide benefit.”

“If there’s one message I want to communicate to the referring physician community, it’s that we really do have the latest and greatest treatment options here at Tufts Medical Center for ad-vanced and recurrent colon and rectal cancers,” says Orkin. “And we have a sincere desire to interact with referring doctors by providing very responsive and immediately available service to them and their patients. It’s my habit to send out a consultation note within 24 hours of a patient being seen. Similarly, I’ll send operative reports and discharge summaries within 24 hours, too.”

“We’re also happy to work with community medical and radiation oncologists since, a lot of the time, patients want to have their surgery here at our academic medical center, but get chemotherapy or radiation therapy close to home,” he adds. “We’re all about facilitating the highest quality patient care and convenience.” o

TREATMENT OPTIONS continued

“If there’s one message I want to

communicate to the referring

physician community, it’s that

we have the latest treatment op-

tions here at Tufts Medical Cen-

ter for advanced and recurrent

colon and rectal cancers.”— BRUCE ORKIN, MD

Good Medicine 7

TOGETHERWORKING

Real experiences from our referring physicians

At Tufts Medical Center, we value our referring physician partners and are committed to doing all we can to make it easy for you to refer your patients here. It

is our mission to ensure that they, and you, have a positive experience during the entire referral process. If you have a story to tell about your experience with

Tufts Medical Center, please contact us at [email protected]. We would love to include it in a future Working Together column.

Michael J. Higgins, MD Michael J. Higgins, MD, a physician at Internal Medicine Foxboro, has been part of many physician groups and affiliations throughout his medical career, but started regularly referring patients to Tufts Medical Center specialists two years ago.

Higgins says his experiences with Tufts Medical Center specialists have been over-whelmingly positive. “I am very pleased with the care my patients have received. I have also been happy with how easily my patients can make appointments. The NEQCA [New England Quality Care Alliance] preferred referral line has worked very well; Nancy Limas and Susan O’Donnell do an excellent job, and my patients do not have to wait long to be seen,” says Higgins.

Quality of patient care and patient satisfaction are important considerations for Higgins when he chooses a specialist for his patients. “Tufts physicians have always provided exemplary care,” says Higgins. “And I like when my patients come back to me and say they’ve had a positive experience. I can’t recall ever hearing a patient complain about a physician they saw at Tufts,” he says.

“Working with specialists at Tufts has also been a positive experience for me; they are personable, easy to communicate with and quick at getting patient information back to me. My patients never fall into a ‘black box’ while being cared for, unlike my experi-ences with other medical centers. Tufts’ specialists always keep me in the loop with my patients’ care; it’s great to be part of the team,” Higgins says.

“My patients say they never feel like just a number; they receive very personal treatment at Tufts Medical Center,” he adds.

Higgins recalls a particular case where his patient was extremely satisfied.“In the fall of 2008, I diagnosed a patient with kidney cancer. This patient traveled every winter and did not want this particular winter to be an exception. Tufts Medical Center’s Dr. Carpinito was able to see him quickly and did an excellent job. The patient recov-ered in time to make his annual trip and was extremely thrilled about that. The patient continues to do well.”

As part of the NEQCA network of physicians, Higgins feels assured that his patients will receive quality medical care and have a positive experience. o


It’s been only four years since Alice B. Got-

tlieb, MD, PhD became Chair of Dermatology

and Dermatologist-in-Chief at Tufts Medical

Center. In that time, however, she has put the

Medical Center on the proverbial map when it

comes to dermatological research.

“We’re not only as good as or better than any other Boston hospital, but also among the top centers for psoriasis and psori-atic arthritis research in the United States, with about 15 clinical trials in this field alone currently underway,” she notes. These include investigator-initiated studies as well as participation in national multi-center pharmaceutical trials.

Similarly, in her role as Chair of the Department of Dermatol-ogy and the Harvey B. Ansell Professor of Dermatology at Tufts University School of Medicine, Gottlieb has spearheaded cre-ation of a dermatology residency program and dermatopathlogy

Putting Tufts Medical Center on the Map for Dermatological Research

fellowship program that are attracting young investigators and faculty with research interests.

Gottlieb herself is renowned for her work focusing on psoria-sis and psoriatic arthritis (PsA), chronic inflammatory diseases linked to dysfunctional immune activity. Psoriasis is character-ized by an increase in skin cell generation that produces thick-ened, sometimes itchy or painful lesions covered with excess dead cells that present as white scales. PsA involves painful and often debilitating joint and connective tissue inflammation. Both psoriasis and psoriatic arthritis are associated with increased risk for metabolic syndrome — the cluster of medical disorders, including hypertension and high triglycerides, that increase the risk of cardiovascular disease and diabetes, increased incidence of both myocardial infarction and premature death.

Board-certified in rheumatology and dermatology as well as internal medicine, Gottlieb is uniquely positioned to take advan-tage of advances in rheumatology and apply them to dermatol-ogy. The often self-described “Jewish mother of biologics for psoriasis and psoriatic arthritis” has been directly involved in more than 100 clinical trials in this area, 15 of which are now active at Tufts Medical Center.

Alice B. Gottlieb, MD, PhD

Good Medicine 9

One of these studies is investigating whether children with moderate to severe psoriasis are at increased risk of metabolic syndrome compared to children with warts.

“We know that in adults, psoriasis is an independent risk factor for cardiovascular morbidity and mortality,” Gottlieb ex-plains. “But what happens in children with psoriasis — are they at the same risk for atherosclerotic disease from early on?” She is looking at the various markers for metabolic syndrome as well as measuring flow-mediated dilatation of the brachial artery which, in adults, has been demonstrated to be a marker for atherosclerotic heart disease.

“This is a study in progress, so we’d appreciate referrals of any young patients with psoriasis,” she adds. “It doesn’t just benefit society but also the patient. We’ve detected high LDL and triglycerides in these children, so even though this is a non-interventional study, we’re able to advise follow-up with the child’s PCP so that something can be done sooner rather than later.”

Another investigational study is comparing the mechanism of action of adalimumab (HUMIRA®) to methotrexate — two already FDA-approved treatments — in adult patients with moderate to severe psoriasis.

“Despite the fact that methotrexate has been in use for de-cades, its mechanism of action in treating psoriasis and psori-atic arthritis is not understood, and it doesn’t work as well as the newer drug adalimumab,” Gottlieb says. “So we’re replicat-ing the methodology of the active comparator study between the two, but looking at skin biopsies to get an answer as to why adalimumab works better.”

Gottlieb’s team also is completing a study to evaluate whether a phosphodiesterase inhibitor shown to work well for psoriasis might also be effective in treating eczema and con-tact dermatitis, conditions poorly addressed by existing treatment options.

Patient referrals to these and other studies are always wel-comed and appreciated, and health insurance is not required for most of them. Gottlieb also wants to reassure referring physicians that their patients will be returned to them after a trial.

Gottlieb also has a special appreciation for study enrollees. “All my patients are important, but study volunteers are giving of themselves,” she says. “That makes them excep-tionally important.”

“Clinical research does something good for the patient,” Gottlieb stresses. “And it can tell us more about what’s clini-cally relevant than anything else. Animal models simply can’t tell you as much as one good clinical trial about the patho-genesis of disease because they’re just not great in predictive qualities. For example, in multiple sclerosis research, it was predicted that TNF blockers [TNF is a cytokine that’s a key me-diator of inflammation] would work, but in actual human trials they made the disease worse.”

“Our clinical trials are making patients better, in novel ways not done before,” she adds. “And the patient’s best interests always come first.” o

Current enrOlling dermatOlOgY studies at tuFts mediCal Center

PSorIASIS: NN8226-1848 (SyStemIC)A randomized, double-blind, placebo-controlled, single- and multiple-dose, dose-escalation trial of anti-IL-20 (109-0012) 100 mg/vial in psoriatic subjects, followed by an expansion phase. Investigational drug study.

meChANISm of ACtIoN StuDy: methotrexAte vS. ADAlImumAB (SyStemIC)An investigator-initiated, assessor blinded, randomized study comparing the mechanism of action of adalimumab to methotrexate in subjects with moderate to severe chronic plaque psoriasis. Investigational study with FDA-approved treatments.

AmGeN 20070559 (SyStemIC)A randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of adding methotrexate to etanercept in subjects with moderate to severe plaque psoriasis. Investigational study with FDA-approved treatments.

PAlmAr / PlANtAr PSorIASIS (SyStemIC) An investigator-initiated, open-label study evaluating the efficacy and safety of ustekinumab in patients with moderate to severe Palmar Plantar psoriasis. Investigational use of approved drug.

PSolArA multicenter, open registry of patients with psoriasis who are candidates for systemic therapy including biologics. Registry for patients with psoriasis.

PeDIAtrIC metABolIC SyNDromeAssessor-blinded study of the metabolic syndrome and surrogate markers of increased cardiovascular risk in children with moderate to severe psoriasis compared with age-matched population of children with warts. Comparison study to see if children with psoriasis have an increased risk of metabolic syndrome compared to children with warts.

PSorIAtIC ArthrItIS: CNto1275PSA3001 (SyStemIC) A phase 3 multicenter, randomized, double-blind, placebo-controlled trial of ustekinumab, a fully human anti-IL-12/23p40 monoclonal antibody, administered subcutaneously, in subjects with active psoriatic arthritis. Investigational drug study.

ChroNIC urtICArIA (hIveS): PAtCh teStING (DIAGNoStIC) Contact allergens causing chronic urticaria in a New England area population. Patch testing to evaluate for a possible contact allergen as cause of chronic, idiopathic hives.

SkIN CANCer: PDt for Ak oN lIP PrIor to mohS for SCC A clinical trial of ALA photodynamic therapy for treatment of actinic cheilitis in patients with squamous cell carcinoma of the lip.

PDt for Ak IN orGAN trANSPlANt reCeIPIeNtSA randomized, evaluator-blinded, parallel group comparison of photodynamic therapy with Levulan® topical solution + blue light versus Levulan topical solu-tion vehicle + blue light for the treatment of actinic keratoses and reduction of new non-melanoma skin cancer on the scalp or both forearms in organ transplant recipients.

ClIPt: low-DoSe PDt for uNreSeCtABle CutANeouS tumorSA phase I clinical trial of continuous low irradiance photodynamic therapy for the treatment of cutaneous tumors. Also indicated for chest wall recurrence of breast cancer after surgery and radiation treatment.

If you would like to refer a patient for participation in a Dermatology clinical trial, or have questions about these studies, please contact Nicole Donovan at [email protected], or at 617-636-7462.


Tufts Medical Center Physicians are the

First in New England to Participate in an eXCiting

neW lVad studY

Tufts Medical Center physicians are the first in New England to surgically implant the HeartWare® Left Ventricular Assist Device (LVAD) in a patient as part of the Evaluation of the

HeartWare LVAD System for the Treatment of Advanced Heart Failure.

DOCTOR’S NOTES

If you have a heart failure patient that you think would benefit from lvAD therapy, please call us at: 617-636-CArD (2273)

Good Medicine 11

Tufts Medical Center’s Duc Thinh Pham, MD and David DeNofrio, MD are investigators in this study,

examining the safety and efficacy of the HeartWare® LVAD system in patients diagnosed with refractory, advanced heart failure, who are listed for heart transplantation. Tufts Medical Center is the only hospital in New England partici-pating in the study; and therefore, the only medical center in the area currently offering this investigational device to patients. Other elite institutions in the country participating include Cleveland Clinic, Johns Hopkins Medical Center and Mayo Clinic.

“Our Heart Failure and Cardiac Trans-plantation Program’s participation in this clinical trial affords us the opportunity to explore the added value of this advanced medical technology for our sickest patients from across New England,” says Pham, Surgical Director of Tufts Medical Center’s Heart Failure and Cardiac Trans-plant Center. “It speaks to our commit-ment as a medical center to our patients and the treatment of heart failure.”

The advanced technology of the new HeartWare device, which is smaller than previous versions, has the potential to offer heart failure patients a speedier recovery, with fewer complications and greater long-term reliability. The new device can fit in the palm of a hand and is implanted in the pericardium, the sac around the heart. The device uses magnetic and hydrodynamic forces to rotate an impeller. As the pump operates, there is no contact between the impeller and the body of the device, minimizing the potential for wear and tear, which may lead to greater durability. The LVAD is powered by an external battery pack. The drive line that connects the pump to the battery on this new device is one-third the size of that of its predecessors.

DeNofrio, Medical Director of the Heart Failure and Cardiac Transplant Center, sees great potential for this new device. “Based on results of this trial, our hope is that this new device will gain FDA approval and will offer

improved outcomes and quality of life for thousands of patients who are currently awaiting heart transplantation,” he says.

Although the trial has completed enrollment, investigators have applied for an extension to continue enrolling patients in the study. In addition, Pham and DeNofrio will be participating in the Destination Therapy Trial later this year. The Destination Therapy Trial is a study

Our Heart Failure and Cardiac Transplantation Program’s participation

in this clinical trial affords us the opportunity to explore the added value of

this advanced medical technology for our sickest patients from across New

England,” says Pham, Surgical Director of Tufts Medical Center’s Heart

Failure and Cardiac Transplant Center. “It speaks to our commitment as a

medical center to our patients and the treatment of heart failure.”

that will examine the HeartWare LVAD System as a permanent implant for those patients who do not qualify for heart transplant. o

DuC PhaM, MDSurgical Director, Heart Failure and Cardiac Tranplant Center

medical SchoolUniversity of North Carolina School of Medicine

Postgraduate trainingUniversity of North Carolina; Northwestern University

Board CertificationCardiothoracic Surgery (ABTS), General Surgery (ABS)

Clinical SpecialitiesAdult cardiac surgery, cardiac transplantation

DaviD DENOfRiO, MDDirector, Heart Failure and Cardiac Transplant Center

medical SchoolTufts University School of Medicine

Postgraduate trainingBarnes Hospital; Duke University Medical Center

Board CertificationInternal Medicine, Cardiovascular Disease

Clinical SpecialitiesHeart failure, cardiac transplantation

“


A regular feature introducing the specialists at Tufts Medical Center

CALLON

Tufts Medical Center offers a wealth of expert specialists to assist you in the care of your patients. During the past several years, we have added new physicians in many specialties to better serve you. This feature highlights several of our newest physicians, your new-est referral resources. To learn more about our other new specialists, visit tuftsmedicalcenter.org and click on “find a physician.”

It is one of the most holistic special-

ties in modern medicine, with treat-

ment tailored to address the physical,

emotional and social needs required to

restore a patient’s quality of life. Yet it

is arguably one of the least-understood

medical specialties among many pa-

tients and physicians. “It” is Physical

Medicine and Rehabilitation (PM&R)

— or Physiatry — the comprehensive

management of patients with congenital

or acquired impairments and disabilities

that arise from genetic and metabolic

abnormalities, trauma or other diseases

that affect the neuromuscular, neurolog-

ic, musculoskeletal, vascular and other

organ systems.

Joseph A. Hanak, MD, FAAPMR, Chief

of the Adult Division of Physical Medi-

cine and Rehabilitation at Tufts Medical

Center, and four other physiatrists lead

an interdisciplinary team that helps

restore physical function, relieve pain,

PHYSICAL MEDICINE AND REHABILITATION

and minimize the psychological, social

and vocational impacts of disabling

injury or illness in adult patients — with-

out surgery. This team includes physi-

cal therapists, occupational therapists,

recreational therapists, rehabilitation

nurses, psychologists, social workers

and speech-language pathologists.

Because there is frequent crossover

among the specialties, Hanak and his

team work closely with primary care

physicians, orthopedic surgeons,

neurosurgeons, rheumatologists, neu-

rologists, psychiatrists, and anesthesia

pain specialists.

“We diagnose and treat patients with

a wide spectrum of conditions due to

congenital or acquired injuries or patho-

logical processes that lead to impair-

ments or disabilities,” Hanak explains.

These conditions include stroke, spastic-

ity, spinal cord injury, spine/back pain,

arthritis, fibromyalgia, myofascial pain,

muscular dystrophy, multiple sclerosis,

cerebral palsy, neck, shoulder and arm

pain, torticollis, dystonia, chronic head-

ache, cancer pain, neuropathic pain in

diabetic patients, cognitive deficits, gait

and balance issues, amputations and

deconditioning.

One of the chief advantages of refer-

ring a patient with musculoskeletal

issues to a physiatrist is the specialty’s

emphasis on prevention, wellness and

conservative medical treatment, along

with its extensive arsenal of treatment

options.

“What we’re best at is coordinating the

rehabilitative care of patients with these

diverse and complex conditions, and

specifying what types of treatment the

individual should have,” Hanak says.

Hanak and his team also perform

diagnostic and therapeutic phenol nerve

blocks, and botox injections to assess

and treat contractures and spasticity.

Good Medicine 13Good Medicine 13

JOSEPh a. haNak, MD, faaPMRChief, Adult Division of Physical Medicine and Rehabilitation at Tufts Medical CenterResidency Program Director, Tufts PM&R Program Assistant Clinical Professor, Tufts University School of Medicine

medical SchoolMedical University of Pecs, Hungary

Postgraduate trainingTufts Medical Center, Metrowest Medical Center

Board CertificationPhysical Medicine and Rehabilitation

aDulT & aDOlESCENT OuTPaTiENT SERviCESRina M. Bloch, MD 617-636-3003Kyung-Ae (Carol) Hahn, MD 617-636-5631Joseph A. Hanak, MD 617-636-5032Alice X. Truong, MD 617-636-3003

aDulT iNPaTiENT SERviCES (provided at New England Sinai Hospital and Rehabilitation Center, Stoughton, Mass.) Heidi K. Wennemer, DO 781-297-1315

They assist in intrathecal baclofen pump

trials as well as perform interventional

spine, trigger point, and bursal and

intra-articular injections. The physicians

write for assistive devices, braces, splints

and orthotics/prosthetics, and refer to

therapists for appropriate directed

exercises and treatment plans.

“When Physical Medicine and Reha-

bilitation sees a patient sooner rather

than later, chances are that we can help.

With our comprehensiveness and holis-

tic approach, we provide another set

of eyes,” he says.

“Our approach is to look at the cause

rather than just treating the symptoms.

For example, if a patient comes in with

lower back pain, we look at the whole

body, not just the lower back, to see

what’s causing it,” he says.

After a comprehensive evaluation,

physiatry emphasizes evidence-based

treatment that is tailored to the individu-

al patient’s goals.

“If I have two 60-year-old patients with

osteoarthritis of the knee, and one’s a

tennis player and the other is sedentary,

their goals for the outcome of treatment

are different, so their treatment plans

will be different,” Hanak explains. “Each

patient is treated as an individual.”

So when is a referral to a physiatrist

warranted?

“When it’s a musculoskeletal issue,

physiatry should be the first-line referral

because we look at all the conservative

treatments that are available, so the

patient can avoid surgery if possible,”

Hanak adds.

“We will make referrals to our surgical

colleagues when appropriate,” he says.

“If there is any question of whether

a physiatry referral is suitable, we wel-

come calls from our community-based

colleagues,” he says. “We’re here to assist

in the care of their patients; we work

together to complement their care.”

“A lot of patients we deal with have

seen many specialists before they see

us,” adds Physiatrist Alice X. Truong,

MD. “By the time they come to us,

they’ve ‘hit the wall’ and don’t know

what else to do.”

“Our role kicks in with adaptive

equipment, therapy and some psychol-

ogy about how to deal with everyday

life,” Truong says. “We help patients set

realistic goals regarding their daily living

activities and functional mobility; we

then help them achieve these goals and

have a better quality of life.”

It all comes down to patients with

musculoskeletal or neuromuscular dis-

orders seeing a physiatrist sooner rather

than later.

“It’s rare that we see a patient that we

can’t help,” Hanak says. “We work hard

to help patients heal, and do our best to

educate them on their condition. Having

a better understanding of a condition

can be very therapeutic in itself.” o


Diabetes ManagementPrevention and LifeStyLe ChangeS Q&aWith riChard d. SiegeL, Md

aCCOrding tO tHe ameriCan diaBetes assOCiatiOn, approximately 24 million people in the United States have diabetes and more than 50 million are at risk for developing the disease. As of 2007, diabetes ranked as the seventh leading cause of death in the country. With a growing population of newly diagnosed diabetics, it is important to be proactive in the prevention of this chronic illness.

Richard D. Siegel, MD, Co-Director of the Diabetes Center at Tufts Medical Center and an expert in diabetes, answers some common questions about type 2 diabetes, the most common form of the disease.

What is type 2 diabetes?Type 2 diabetes is the most common form of diabetes, a disease with high levels of sugar in the blood. The disease is caused by a combination of a relative defi-ciency of insulin and an inability by the body to use insulin appropriately. Insulin is a hormone made in the pancreas which allows the body to use and store sugars and starches.

How is type 2 diabetes treated?It is treated with changes in lifestyle including diet and activity. Many patients may require medications including several classes of pills or injectable medications including insulin. For selected patients who are significantly overweight, surgical procedures including gastric bypass surgery and adjustable gastric banding may also help to lower blood sugars.

Is there a cure for type 2 diabetes?Currently, there is no true “cure” for type 2 diabetes. However, patients may achieve a “remission” and have very normal sugars if they achieve significant weight loss and lifestyle changes early in the disease process.

What complications can arise as a result of having type 2 diabetes?The goal of treatment is to avoid the effect of high blood sugars on different parts of the body. Complications after many years of high sugars include problems with the eyes, kidneys, nerves, heart and blood vessels.

What are symptoms or early signs of type 2 diabetes?Many people will not have any specific symptoms and will only find out about their diabetes from a blood test. For those who do experience warning signs, these can include frequent thirst, frequent urination, fatigue and unexplained weight loss.

Health Sheet

RiChaRD D. SiEgEl, MDCo-Director, Diabetes Center Tufts Medical Center

medical SchoolAlbany Medical College of Union University

Postgraduate trainingBoston University Medical Center; Tufts Medical Center

Board CertificationEndocrinology, Diabetes and Metabolism, Internal Medicine

Clinical SpecialtiesInpatient and outpatient diabetes, obesity, general endocrinology

DOCTOR’S NOTES

Contact our Diabetes Center at 617-636-5689.

Good Medicine 15

A quick resource guide for your patients: clip and copy or download at www.tuftsmedicalcenter.org/diabetesmanagement

Are there any genetic predispositions for type 2 diabetes? Are any persons at greater risk?Type 2 diabetes frequently runs in families. Weight gain over time may bring out the predisposition toward the disease. It occurs more commonly in Native Americans, Latino Americans, African Americans and Asian Americans as compared to Caucasians. The risk for diabetes increases with age. Women with diabetes during pregnancy (gesta-tional diabetes) are also at higher risk for getting type 2 diabetes later in life.

How does diet and physical activity help prevent or delay the disease?A research study published earlier in the decade showed that intensive lifestyle changes can at least delay getting type 2 diabetes in people who are at high risk for the disease. These people made changes to their diet by cutting calories and ex-ercising for 150 minutes per week with a goal of losing about seven percent of their weight (about 10–20 lbs.). While it is not clear if these lifestyle changes truly prevented diabetes, it is felt that these changes allow the body to make and use insulin more effectively. The intensive lifestyle changes were better than a medication in delaying the onset of the disease. A recent update to this study showed that the lifestyle changes continued to be effective up to 10 years afterwards.

How will type 2 diabetes treatment affect my lifestyle?Initial treatment of type 2 diabetes involves education and counseling by a health care team, including a primary care provider, registered dietitian and, very often, a diabetes edu-cator. Education helps people to incorporate diet, exercise and medication lifestyle changes into a daily routine. Some people may need to learn how to monitor their blood sugar or how to use injectable medication such as insulin.

Due to the increasing rate of type 2 diabetes in our society, how does this impact our rising health care costs now and in the future?In 2007, it was estimated that the national cost of diabetes in the United States was about $174 billion. About one third of this cost is “indirect” which includes the cost of reduced productivity at work. About $1 in $10 health care dollars has been attributed to diabetes. The incidence of type 2 diabetes continues to increase. If a small percentage of cases are prevented, it would have a significant impact on reducing health care costs in our country. o


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www.tuftsmedicalcenter.org

Have Our Physicians Visit You If you would like to schedule a meeting with any of our physicians or have them to your hospital for grand rounds or other educational sessions, please contact Physician Liaison Jennifer Roberts at 617 636-1398 or [email protected]

Physicians’ Referral GuideFor a copy of our most recent Physicians’ Referral Guide, with a complete listing of all our physicians, their specialties, and contact information, call Jennifer Roberts at 617-636-1398 or email [email protected]

Refer a Patient for Inpatient Care Use our simple one call service to admit a patient any time – 24 hours a day, 7 days a week – at 877-OK-TUFTS

Working Together Is Good Medicine is for physicians who are interested in learning more about referring their patients to Tufts Medical Center. We value your partnership with us and are committed to doing all we can to make it easy for you to refer your patients to us. It is our mission to ensure that they, and you, have a positive experience while benefiting from some of the finest care and cutting-edge research available in New England.

Working Together Is Good Medicine is published quarterly by Tufts Medical Center. For more information, contact the Office of Public Affairs and Communications at Tufts Medical Center, 617 636-0200 or [email protected]

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