TAG: "Surgery"

Surgery for terminal cancer patients still common

Surgeons increasingly selective in deciding whether to operate.

By Dorsey Griffith, UC Davis

The number of surgeries performed on terminally ill cancer patients has not dropped in recent years­, despite more attention to the importance of less invasive care for these patients to relieve symptoms and improve quality of life. But new research from UC Davis also finds that the morbidity and mortality among patients with terminal cancer has declined because surgeons are selecting to operate on healthier patients.

The study, “Current Perioperative Outcomes for Patients with Disseminated Care Undergoing Surgery” was published online this week in the Journal of Surgical Research.

“Surgeons are becoming wiser,” said study lead author Sarah Bateni, a UC Davis resident surgeon. “Our research suggests that surgeons may be operating on healthier patients who are more likely to recover well from an operation. These are patients who can perform activities of daily living without assistance, for example.”

Bateni’s interest in the appropriate surgical care of people with late-stage cancer grew from observing terminally ill patients whose acute problems were addressed through surgery, and who then suffered complications resulting in lengthy stays in intensive care units, and even in death.

“It is common that patients end up dying in the intensive care unit instead of being managed with medication with hopes of returning home with their families, including with hospice care,” she said.

For the study, Bateni used the American College of Surgeons National Surgical Quality Improvement Program between 2006 and 2010 to identify 21,755 patients with stage IV cancer, meaning that the disease had metastasized, or spread, beyond the primary tumor site.

Over the five years in the study period, surgical interventions declined just slightly, from 1.9 percent to 1.6 percent of all procedures. The most frequent operations were surgeries to alleviate bowel obstructions among cancer patients with metastatic disease.

Also over time, the patients undergoing surgery were more independent and fewer had experienced dramatic weight loss or sepsis, a serious blood infection. These characteristics are generally associated with poorer surgical outcomes.

The patients’ rate of morbidity, a measure of illness, significantly decreased, from 33.7 percent in 2006 to 26.6 percent in 2010. Mortality declined as well, although more modestly, from 10. 4 percent to 9.3 percent over the study period.

Why surgeons continue to operate on patients at such high risk for complications and death is due to several factors, Bateni said.

“Some of it has to do with the patients and families,” she said. “If the patient is uncomfortable, the family wants a solution. In some cases, the surgeon also may be too optimistic about what the surgical outcome will be.”

What Bateni also found was that just 3 percent of the patients with terminal cancer had Do Not Resuscitate (DNR) directives in place at the time of their surgery. DNRs, part of advanced directives used in end-of-life planning, direct physicians to withhold advanced life support if the patient stops breathing or their heart stops beating.

Bateni said the study results imply that patients, families and care providers, including surgeons, are often delaying discussions about the goals of the care and the priorities at the end of life.

She cautioned that delaying end-of-life discussions can have serious consequences because it can lead to delayed referrals for palliative care and hospice. In addition, the patient risks undergoing multiple invasive, uncomfortable procedures in an attempt to prolong life, despite being against the patient’s goals of care and how they wish to spend their final days of life.

“It’s really important that the doctor has an end-of-life, goals-of-care discussion prior to the time that the patient comes into the hospital with an acute illness,” she said. ”Patients should be referred to a palliative care counselor or  have a comprehensive end-of-life discussion to ensure that their goals are respected as soon as they are diagnosed with cancer, especially those with cancers that have a high mortality rate.”

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UCLA medical center statement on behalf of Kareem Abdul-Jabbar

UCLA alum, NBA Hall of Fame member, continues recovery from quadruple bypass surgery.

This morning (April 29), Kareem Abdul-Jabbar was experiencing some dizziness following his April 16 quadruple bypass surgery. He contacted his physicians, who told him to come to the emergency department at Ronald Reagan UCLA Medical Center. He was evaluated by his surgeon and cardiologist. After a battery of tests, they found no complications. Abdul-Jabbar was discharged from the emergency department and is back home continuing his recovery. His surgeon, Dr. Richard Shemin, said it is not uncommon for patients to experience some symptoms that require ruling out serious problems following major heart surgery. Shemin added that Abdul-Jabbar did the right thing by coming in to see his doctors.

There will be no media interviews or additional information from Abdul-Jabbar, his physician or his spokesperson.

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Why do obese men get bariatric surgery far less than women?

Demographic, socioeconomic, cultural factors all add to sizable gender gap.

UC San Diego School of Medicine researchers report men undergo bariatric surgeries in far lower numbers than women.

By Bonnie Ward, UC San Diego

A new study by researchers at the UC San Diego School of Medicine has identified demographic, socioeconomic and cultural factors that contribute to a major gender disparity among U.S. men and women undergoing weight loss surgeries. Men undergo the surgeries in far lower numbers than women.

The study is published in the March issue of the Journal of Laparoendoscopic & Advanced Surgical Techniques.

Eighty percent of patients who undergo bariatric surgery, which involve procedures that either limit the amount of food that can be consumed or reduce food absorption, are female, despite equal rates of obesity among American men and women.

“The results of this study should raise awareness in men about the complications that obesity brings to their health,” said senior author Santiago Horgan, M.D., chief of the Division of Minimally Invasive Surgery at UC San Diego Health System. “Even though we have a 50-50 percent split in obesity rates among U.S. men and women, women get 80 percent of the bariatric surgeries and men only 20 percent. That’s a very uneven distribution.”

Horgan said the study explored non-biological factors that may be causing fewer men to seek weight reduction surgery. Among the factors identified that may influence gender distribution:  surgery eligibility, insurance coverage, health awareness and perception of body image. Age was also a factor.

The researchers examined data from 190,705 U.S. patients who underwent bariatric surgery (93 percent gastric bypass, 7 percent sleeve gastrectomy) from 1998-2010.

“We think some of it is cultural,” said Horgan. “Women seem to be more aware of the problems obesity brings to health. They are much more willing to look at surgical weight loss earlier in life, whereas men tend to wait until they have more co-morbidities (adverse health conditions).”

He pointed to a 2014 study from Kansas State University showing differences in health satisfaction between obese men and women. That study found that 72.8–94 percent of overweight and obese men were satisfied with their health as compared to 56.7–85 percent of overweight and obese women.

“This skewed male body perception hinders the likelihood of seeking health care advice,” said Horgan. “This is something we hope to change by educating men about the need to treat obesity earlier, so they don’t develop complications in the future.”

“Bariatric surgery contributes to improving medical conditions associated with obesity, such as diabetes, high blood pressure, high cholesterol, sleep apnea, and arthritis. Men need to wake up to the need to control their obesity.”

Age also plays a pivotal role in the gender differences, said co-author Cristina Harnsberger, M.D., of the UC San Diego Department of Surgery’s Division of Minimally Invasive Surgery, noting more men seek bariatric surgery as they age. “There are still more women than men, but when people get into their 70s, the split narrows to about 70 percent women to 30 percent men,” she said. “Once they get sicker and older, men begin to seek bariatric surgery in greater numbers.”

Another possible explanation for the higher rate of females undergoing bariatric surgery is greater eligibility, said the researchers. A recent analysis of racial trends in U.S. bariatric surgery by Medical University of South Carolina researchers found an overall larger proportion of females were eligible for the surgery from 1999–2010. According to the National Hospital Discharge Survey and National Health and Nutrition Examination Survey databases, the proportion held true across ethnic groups.

The scientists did note that race and income appeared to affect male to female surgery ratios within certain populations. “A significantly higher female percentage was observed in counties with lower median income as well as in some ethnic groups,” said Hans Fuchs, M.D., co-first author with Ryan Broderick, M.D., both of the UC San Diego Division of Minimally Invasive Surgery. “This suggests that cultural differences and racial differences may accentuate the gender disparity,” added Broderick.

Co-authors include Bryan J. Sandler, Garth R. Jacobsen and David C. Chang, all at UCSD.

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Kareem Abdul-Jabbar undergoes coronary bypass surgery

UCLA alum, NBA Hall of Fame member, has surgery at Ronald Reagan UCLA Medical Center.

UCLA Health is issuing this statement at the request of Kareem Abdul-Jabbar, the NBA’s all-time leading scorer and member of the Basketball Hall of Fame:

Kareem Abdul-Jabbar was admitted to Ronald Reagan UCLA Medical Center this week with cardiovascular disease, and he underwent quadruple coronary bypass surgery on April 16. The operation was performed by Dr. Richard Shemin, UCLA’s chief of cardiac surgery.

Shemin said the surgery was successful and he expects Abdul-Jabbar to make a full recovery.

At this time, Abdul-Jabbar would like to thank his surgical team and the medical staff at UCLA, his alma mater, for the excellent care he has received. He is looking forward to getting back to his normal activities soon.

He asks that you keep him in your thoughts and, most importantly, cherish and live each day to its fullest.

For those wanting to send well wishes, he thanks you in advance and asks that you support those in your own community who may be suffering from various health issues.

There will be no media interviews or additional information from Abdul-Jabbar, his physician or his spokesperson. However, news media planning stand-ups at the hospital must park news vans in the southbound lane of Westwood Boulevard, south of Westwood Plaza, between Le Conte Avenue and Med Plaza Circle (in the far right lane).

Media contact:
UCLA Health Sciences Media Relations
(310) 794-0777

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Unnecessary preoperative testing still done on cataract patients

UCSF researchers find testing based on provider behavior, not patient traits.

By Scott Maier, UC San Francisco

Although routine preoperative testing is not indicated for patients undergoing cataract surgery, researchers at UC San Francisco have found that it is still a common occurrence and is driven primarily by provider practice patterns rather than patient characteristics.

Their study appears in the April 16 issue of the New England Journal of Medicine.

“Our study shows that routine preoperative testing still occurs in Medicare patients undergoing cataract surgery, even though it is one of the safest procedures out there,” said lead author Catherine Chen, M.D., M.P.H., resident physician in the Department of Anesthesia and Perioperative Care at UCSF. “The major professional societies have agreed for more than a decade that routine testing doesn’t improve outcomes from surgery.”

According to the study background, cataract surgery is the most common elective surgery among Medicare beneficiaries, with 1.7 million surgeries annually. The average surgery is just 18 minutes long, and virtually all are performed in an outpatient setting with eye drops for anesthesia.

Chen and her colleagues analyzed a cohort of Medicare beneficiaries undergoing cataract surgery in 2011 to determine the frequency and cost of preoperative testing and office visits in the month before surgery.

Among nearly 441,000 patients studied, 53 percent had at least one preoperative test, and 52 percent had a preoperative office visit in the month before surgery. Testing and office visit expenses were $4.8 million (42 percent) and $12.4 million (78 percent) higher, respectively, than the average monthly expenditures during the preceding 11 months.

However, the researchers found testing varied widely among ophthalmologists and seemed to have little to do with patient characteristics. Although most ophthalmologists did not appear to do additional testing during the preoperative month, a small group of ophthalmologists accounted for more than 84 percent of the excess tests performed.

“The ophthalmologist who operated on the patient was a stronger predictor of whether patients were tested than any other variable we looked at, which implies that it doesn’t matter whether a patient is sick or healthy,” Chen said. “There are certain doctors who will always order tests in their patients just because that patient is having surgery, even though studies have shown that these tests don’t make a difference since cataract surgery itself is so low risk.”

“In this study, we found that the excess testing occurred primarily among a small number of physicians who are readily identifiable using claims data,” said senior author R. Adams Dudley, M.D., M.B.A., director of the Center for Healthcare Value at The Philip R. Lee Institute for Health Policy Studies at UCSF. “This study hopefully will encourage these physicians to examine their practice and make a change, but it also demonstrates that payers like Medicare could use their own data to figure out which doctors they need to talk to about this.”

Chen is careful to point out it is not necessarily the ophthalmologist alone who is driving testing.

“We can’t tell which doctor – the ophthalmologist, the anesthesiologist or the primary care provider – actually ordered the tests,” Chen said. “Ophthalmologists usually work closely with anesthesiologists and primary care physicians to evaluate their patients before surgery. That being said, our study is important because it shows that claims data can be used to eliminate wasteful spending without negatively impacting the quality of care provided to Medicare patients.”

Other UCSF contributors to the New England Journal of Medicine study were Grace Lin, M.D., M.A.S., assistant professor of general internal medicine; Naomi Bardach, M.D., M.A.S., assistant professor of pediatrics; W. John Boscardin, Ph.D., professor of epidemiology and biostatistics; and Adrian Gelb, M.D., Ch.B., professor, Mervyn Maze, M.B., Ch.B., professor, and Michael Gropper, M.D., Ph.D., professor and interim chair, anesthesia and perioperative care. Theodore Clay, M.S., statistician at Clay Software & Statistics, also contributed.

Funding was provided by the Foundation for Anesthesia Education and Research and The Grove Foundation.

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Young physicians take over controls to learn robotic surgery

UCLA offers large-scale training on these advanced techniques for first time.

Photo by Reed Hutchinson, UCLA

By Rachel Champeau, UCLA

UCLA’s Center for Advanced Surgical and Interventional Technology and Surgical Science Laboratory are holding UCLA’s first-ever, grand scale robotic surgical training sessions. Nearly 60 residents, fellows and junior faculty from various surgical specialties and hospitals are attending the two-day event, which concludes today.

The young doctors from general surgery, gynecology, urology, head and neck, and thoracic surgery are taking part in simulation sessions using advanced trainers and Da Vinci surgical robots in order to learn and hone their skills in this expanding area of medicine.

The trainees are learning this advanced form of minimally invasive surgery with the help of senior UCLA physicians, assisted by industry trainers, and using robots and other equipment from Intuitive Surgical, Mimic Technologies, SurgiQuest and others. The trainees come from Ronald Reagan UCLA Medical Center; UCLA Medical Center, Santa Monica; Harbor-UCLA Medical Center; Olive View-UCLA Medical Center and Cedar Sinai hospitals, among other institutions.

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New incisionless surgery to treat enlarged prostate

8-minute procedure relieves urinary symptoms, preserves sexual function.

Mike Hsieh, UC San Diego

By Jackie Carr, UC San Diego

By age 60, more than 50 percent of men in the United States suffer from benign prostatic hyperplasia (BPH), a condition that leads to annoying changes in urinary flow. While medical therapy is usually the first line of treatment, a new minimally invasive implant can dramatically reduce symptoms for men.

“This is a safe procedure for men with BPH to improve urination while preserving sexual function,” said Mike Hsieh, M.D., urologist at UC San Diego Health System. “This endoscopic procedure is done on an outpatient basis under light sedation with virtually no side effects.”

The prostate is a walnut-sized gland that sits below the bladder. When the prostate becomes enlarged, it can restrict or block urine flow causing interrupted or weak urine stream, leakage, urge incontinence and more frequent urination, especially at night.

“More than half of all men in their 60s and as many as 80 percent of men in their 70s and 80s have some symptoms of BPH,” said Hsieh. “This is an excellent alternative to traditional surgeries that require removal of prostate tissue, which can cause complications such as erectile and ejaculatory dysfunction.”

The implant is comprised of a series of tiny permanent sutures that lift the enlarged prostate open so that it does not interfere with the urethra or bladder anatomy. The implants are delivered through a hollow needle and into the prostate. No urinary catheter is needed post-procedure. Side effects may include burning and blood in the urine during the first 24 hours after the procedure.

The device, called UroLift, was FDA approved in 2013. UC San Diego Health System showcased this new procedure in a live-surgery during the 8th annual UC San Diego School of Medicine urology postgraduate course.

Hsieh specializes in male fertility and men’s health. He treats sexual dysfunction, including low testosterone, erectile dysfunction and Peyronie’s disease. He is also a recognized expert in treating male infertility, including ejaculatory disorder, hormone imbalance, sperm production impairment and genetic causes of infertility.

To learn more about urological care at UC San Diego Health System, visit health.ucsd.edu/specialties/surgery/urology.

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On the road to recovery

UC Irvine spinal experts help patient get back on his feet after motorcycle accident.

Ruben Barajas remembers the accident in snapshots: Riding his motorcycle to class at Cal State Fullerton. An inattentive driver veering into his lane. Lying on the freeway, unable to move or breathe. Finally, paramedics giving him a lifesaving rush of oxygen.

“That first taste of air after struggling to breathe was absolutely beautiful,” he says. He also remembers the ambulance ride to UC Irvine Medical Center in Orange, his anxious family, neurological tests and learning at age 25 he might never walk again.

His neurosurgeon, Dr. Daniel Yanni, explains: “Ruben had two shattered vertebrae in his neck — a severe injury that paralyzed his arms and legs. His chances of regaining movement were small, but we tried to ensure the best possible outcome by treating him quickly and aggressively.”

That night, Yanni removed the bone fragments that were compressing Barajas’ spinal cord, replacing the broken bones with a metal cage, plate and screws.

The next day, he excised more bone from the back of Barajas’ spine and anchored the cage in place with metal rods and screws. Both surgeries required tremendous surgical skill and precision.

Barajas was treated for other injuries, too — a broken right arm, fractured ankle and mangled right toe. The neurosurgical and neurocritical care team did everything possible to aid his recovery, even maintaining artificially high blood pressure to improve blood flow to the spinal cord.

Heavily sedated for two weeks, Barajas has no memory of the surgery. But he does remember beginning physical therapy at UC Irvine Health. “My right leg was in a brace and my right arm in a sling,” he says. “It was the hardest work I’ve ever done.” After three weeks at UC Irvine Health, he was transferred to a rehabilitation hospital, where he continued to regain the use of his arms and legs.

The hard work and intensive medical care paid off. In January 2013, six months after the accident, Barajas took his first steps. “Just standing up was a shock,” he says. “I’d forgotten how different the world looks when you’re upright.”

He left the rehabilitation hospital in March using only a walker. By October, he was driving and working at a gym part time. In August 2014, two years after the accident, Barajas returned to college with a new career in mind. “I want to help people when they’re at their most vulnerable,” he says. “I can do that best as a doctor specializing in rehabilitation medicine.”

Yanni describes Barajas’ recovery as “truly spectacular.” Barajas credits Yanni: “I’m truly blessed that he had the expertise to put me back together,” he says. “I’m blessed beyond belief.”

To learn more about UC Irvine Health neurosurgical spine services, visit ucirvinehealth.org/spine.

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UCLA offers pioneering surgery for phrenic nerve damage

West Coast’s only medical center with surgery for the rare condition.

By Amy Albin, UCLA

David Powell could not catch his breath.

The 35-year-old from San Diego got winded walking up the stairs, exercising or even just bending over to tie his shoes. His favorite pastime, hiking, became impossible. But doctors, unable to diagnose his condition, told Powell that he would just have to live with it.

Frustrated, he turned to the Internet and discovered that his symptoms could be the result of phrenic nerve damage. The phrenic nerves — there is one on each side of the body — send messages from the brain to the diaphragm telling the body to breathe. Powell also learned that the damage could possibly be repaired through surgery.

Injuries to the phrenic nerve can occur in a variety of ways, including injections of medicine in the neck prior to shoulder surgery or to treat pain, chiropractic adjustments of the neck, or neck, chest or vascular surgery. In addition, scar tissue can form in the neck and compress the nerve. Patients are often misdiagnosed because the symptoms are similar to those of pneumonia or asthma. Doctors typically diagnose phrenic nerve injury by conducting a physical exam, asking the patient about previous medical treatments that may have affected the neck or chest, and considering whether the patient has severe shortness of breath and is unable to perform simple day-to-day activities.

“If we suspect that it is a phrenic nerve injury, there are a couple of tests that can help us make a definitive diagnosis,” said Dr. Reza Jarrahy, an associate clinical professor of plastic and reconstructive surgery at UCLA.

Jarrahy said surgery for the disorder aims to identify the exact location of the injury and then repair it by removing the scar tissue and freeing up the nerve. In some cases, surgeons take a small piece of nerve from the person’s leg and use it as a bypass around the injured nerve, creating a clean route for the nerve signal from the brain to the diaphragm.

Although many people notice an improvement immediately following surgery, it may take a year or more for the new nerve to regrow and form new connections in the body. Also, the diaphragm muscle must be retrained and strengthened again.

“Even though diaphragm paralysis impacts the respiratory system, the underlying pathology is focused on nerves and muscles,” said Dr. Matthew Kaufman, a voluntary assistant clinical professor at the David Geffen School of Medicine at UCLA. “As a result, many medical professionals are unaware of phrenic nerve surgery.”

In 2007, Kaufman began specializing in the procedure at his plastic and reconstructive surgery practice in Shrewsbury, New Jersey. In 2013, he teamed up with Jarrahy to offer the surgery at UCLA. Together, the two centers have treated more than 100 patients, up to 80 percent of whom have made a partial or complete recovery.

“These patients suffer tremendously and yet have very few options,” Jarrahy said. “This surgery offers hope to patients who previously had none and were resigned to dealing with this debilitating condition for life.”

Powell underwent the procedure in August 2013, and is no longer sidelined by his condition. He can once again enjoy all of his favorite activities.

“It’s so much better,” he said. “Before, I pretty much couldn’t do anything, but now I can do exercise—hike, ride my bike and swim.”

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Caring for the child’s brain

Pediatric Brain Center provides holistic care for patients’ full range of brain-related needs.

Audrey Price

By Kathleen Masterson, UC San Francisco

Fifteen-year-old Audrey Price slowly reaches for an orange plastic cup sitting on the counter. In a concerted effort, her fingers close around it, and she lifts it to chest height, shaking ever so slightly.

For Audrey, this simple act marks a tremendous journey from diagnosis to brain surgery to therapy and slow healing.

Just 11 months ago, she was living a typical middle-schooler’s life in a Bay Area suburb, hanging out with friends, playing tennis and obsessing over the British boy band, One Direction.

Then Audrey began developing weakness in her right side. After a series of doctor’s appointments, she ended up visiting a neurologist, who ordered scans of her brain that showed an aneurysm the size of a golf ball pressing on her brain stem.

That’s when her neurologist called UC San Francisco.

Audrey was brought into the newly formed Pediatric Brain Center at the UCSF Benioff Children’s Hospital San Francisco, which integrates neurology, neurosurgery, physical and occupational therapy, speech, social work and neuro-psychology to provide seamless holistic care for patients’ full range of brain-related needs. It’s one of just a few specialized pediatric brain centers in the U.S.

The center’s unique structure and specializations ended up being an ideal match for Audrey’s rare and complex condition.

Heather Fullerton and Nalin Gupta lead UC San Francisco's Pediatric Brain Center, which opens a new, centralized location at the new UCSF Benioff Children's Hospital at Mission Bay on Feb. 1. (Photo by Cindy Chew)

Bringing the doctors to the patient

The Pediatric Brain Center was founded about two years ago, spearheaded by Heather Fullerton, M.D., and Nalin Gupta, M.D. The center brings together a diverse range of UCSF experts from across multiple departments to treat patients together, as a team.

Rather than the typical experience in which a patient may see one doctor and then be referred to another specialist, and then another, chasing multiple appointments over weeks, at the Pediatric Brain Center the physicians, nurses and other key staff coordinate the care around the patient. One coordinator books all the patient’s appointments, from check-ups to arranging tests to surgery, and each patient is treated by a team assembled specifically to meet his or her unique medical needs.

“The goal was to make not only the patient experience, but also the problem solving and treatment, more rational. We wanted to be able to design our care around the patient’s medical issue, as opposed to simply following the organizational structure of the institution,” said Gupta.

Initially the center existed mainly as an organization change, with all the experts still located in separate offices at Parnassus. With the Feb. 1 opening of the UCSF Medical Center at Mission Bay, the Pediatric Brain Center will soon have it’s own central location to further streamline the patient experience.

“It’s so much easier for the family to have one place to go for all their child’s care, all the way from the initial treatment to rehabilitation,” said Fullerton.

Unique expertise in research and care

Having a centralized space will help make the patient experience smoother, but the crux of the Pediatric Brain Center is its network of highly specialized researchers, clinicians and surgeons.

“Having clinicians and researchers together helps inform what we study,” said Fullerton, a practicing neurologist who also researches pediatric strokes. “So many of our clinicians are also researchers, so when a question comes up in clinic, we can use our own local expertise to start the search for an answer. For example if I keep seeing this strange-looking blood vessel, I can turn around and start a study to investigate what’s happening.”

That’s a distinct advantage of an academic medical center. Private practices couldn’t afford the freedom to develop deep expertise in narrow areas, said Gupta. Furthermore, a child’s brain isn’t like the adult brain; treating a growing brain requires specialized neurology expertise.

“With the Pediatric Brain Center, we’re explicitly trying to leverage the strengths of the institution,” said Gupta. “We have people that have lot of expertise in narrow areas, and by definition those are often rare things.”

Building a specialized team

The Pediatric Brain Center brings all these diverse experts together, forming a unique treatment team made up of specialists relevant to each patient’s needs.

That’s vital for patients like Audrey, said Gupta.

“What Audrey had was very rare and complex. She’s an example of type of patient that there isn’t a list of 500 patients like that,” he said. “It’s not like other conditions where we could simply look to see what did we do for last 500.”

So Audrey’s doctors assembled a team of neurologists and neurosurgeons to develop a plan to remove the brain aneurysm.

“Audrey’s surgical team in consultation was so calm, they really explained things really well in terms we understood,” said her mother, Barbara Price. “We left there feeling very relieved this was treatable, that we were not in emergency situation and we had one of best surgical teams in the world that would treat her.”

Audrey’s surgery went well, and the team was able to remove the brain aneurism safely.

However, when she came out of surgery, she could hardly move the right side of her body. Her doctors quickly called in another team member, Jonathan Bixby, M.D., who specializes in physical rehabilitation.

“Unlike some other aspects of medicine, rehabilitation is dependent on how much effort the patient puts in,” said Bixby.

“Audrey was great. With any patient dealing with significant changes to the body, there can be issues adjusting. Audrey adjusted quickly, and was very willing to work with a therapist.”

Ongoing team care

Audrey is continuing to get stronger every day. She does her physical therapy daily at home, has learned to do nearly everything with her left hand and was able to start high school last fall.

She got there after spending six weeks living at the hospital after her surgery; she practiced physical therapy six hours a day, six days a week. It’s exhausting work, but her therapists strived to incorporate Audrey’s interests into her exercises to make it more fun, including using therapy dogs and playing One Direction’s music during sessions.

“The hardest part is not knowing when my body is going to be back to the way it was,” she said. “The doctors said, ‘all brains are different,’ and that was the most frustrating part.”

Throughout her hospital stay, her bed was covered in a fleece blanket with the One Direction’s faces on it, including her favorite singer, Niall.

Barbara Price recalled that one day Audrey came back to her room to find a note atop her One Direction blanket that read something like: “‘Dear Audrey, I’m really proud of all the hard work you’re doing’ then the note quoted lyrics from one of the songs. It was signed,  ‘Love, Niall,” she said with a laugh. One of the doctors had scripted this joking note of encouragement.

“The team was so funny and thoughtful, so we had a lot of laughs that got us through some tough times.”

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UC Davis heart surgeon publishes his model for medical humanitarian aid

J. Nilas Young details a quarter century of establishing cardiac surgery sites in Russia.

J. Nilas Young, UC Davis

By Karen Finney, UC Davis

J. Nilas Young, UC Davis chief of cardiothoracic surgery, has published a landmark article on medical humanitarian aid, detailing his 25 years of experience establishing six cardiac surgery sites in Russia.

The article appears in the December 2014 issue of the prestigious Journal of Thoracic and Cardiovascular Surgery and is also available online.

Young’s UC Davis co-authors were pediatric cardiac surgeon Gary Raff and pediatric critical care physician James Marcin, and his collaborators included colleagues at the Mayo Clinic, Emory University, Childrens Hospital of Wisconsin, Nationwide Childrens Hospital and the Siberian Branch of the Russian Academy of Medical Science.

The article emphasizes the approach of Heart to Heart International Children’s Medical Alliance in developing sustainable medical aid programs with high-quality outcomes, scalability and efficacy. Although focused on a specific class of diseases (congenital heart diseases), the authors believe the model is applicable to other medical humanitarian projects, particularly those that involve complex surgical interventions.

In 2012, Young received the the World of Children Health Award — hailed as the “Nobel Prize for child advocates” — for his international humanitarian efforts to improve pediatric heart care (read the press release).

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First real-time MRI-guided brain surgery for Parkinson’s in SoCal

Deep brain stimulator also can be used to treat other movement disorders.

By Jackie Carr, UC San Diego

Neurosurgeons at UC San Diego Health System are the first in Southern California to implant a deep brain stimulator (DBS) in a patient with Parkinson’s disease using real-time 3-D magnetic resonance image (MRI) guidance.

Parkinson’s disease is a progressive disorder of the nervous system that affects movement. Symptoms include shaking, slowness of movement and difficulty walking. These unpredictable movements are caused by abnormal nerve cell activity in the brain. DBS therapy, like a heart pacemaker, transmits electrical signals to help restore normal activity.

Traditionally, DBS surgery is conducted while the patient is awake, and under pain management. This approach allows surgeons to continuously monitor the patient’s brain function and to ensure accurate placement of the device.

“Now, for some patients, this surgery can be performed in the MRI suite under general anesthesia so that a patient can sleep during the placement of the DBS electrodes,” David Barba, M.D., director of functional neurosurgery, UC San Diego Health System. “Within a few days of DBS therapy, many patients can resume life’s everyday activities.”

“Placing a DBS device while a patient is awake can be exhausting for the patient due to the length of the procedure and the need to perform neurologic testing in the operating room,” added Clark Chen, M.D., Ph.D., director of stereotactic and radiosurgery, UC San Diego Health System. “Fortunately, with continuous real-time MRI monitoring, we can now place the electrode in a safe location that provides maximal neurological benefit while the patient is under the comfort of general anesthesia.”

Bob S. Carter, M.D., Ph.D., professor and chief of neurosurgery and co-director of the UC San Diego Neurological Institute, said the collaborative endeavor introduces a new technology strategy to improve the care of patients with Parkinson’s and other diseases.

“Our capacity to perform these procedures will be further enhanced in the new A. Vassiliadis Family Hospital for Advanced Surgery at Jacobs Medical Center, which opens in 2016,” said Carter.

DBS also can be used to treat other movement disorders, including dystonia, essential tremor and obsessive compulsive disorder. It is in clinical trial testing as treatment for depression.

UC San Diego Health System is an internationally recognized leader in functional neurosurgery. Barba is a pioneer in the neurosurgical treatment of patients affected with movement disorders. Chen is an expert in MRI guided neurosurgery.

To learn more about MRI-guided DBS placement, please visit: health.ucsd.edu.

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