October 21, 2018

Joseph F. Dilustro, MD, FACS

Chief of Neurosurgery, Children’s Hospital of The King’s Daughters;
Director, CHKD Surgical Specialty Group

 

As the region’s senior provider of pediatric neurosurgery services, Dr. Joseph Dilustro handles an astonishingly wide variety of cases at Children’s Hospital of The King’s Daughters.

On any given day, he might be placing a shunt in a fragile premature baby, removing a brain tumor, or handling traumatic head injuries caused by car accidents, falls or child abuse. 

A firm believer in hands-on care, Dr. Dilustro makes rounds, builds powerful connections with patients and their families, and regularly teaches residents at Eastern Virginia Medical School as an assistant professor. 

“I think you have to have a passion for this work,” he says. “The practice of pediatric neurosurgery is dramatically different from adult neurosurgery. To want to do what I do, it has to be in your DNA.”

A Native from New York City, Dr. Dilustro moved to Hampton Roads when his father, who was in the Department of Defense, was transferred here. A few years later, he enrolled at the University of Virginia. He applied early decision to EVMS and a scholarship from the Lincoln-Lane Foundation paved his road back to Hampton Roads. 

“It was a different time back then,” he says. “I remember first-year tuition being $3,200. EVMS was a very young school and I liked that it was a three-year program with no summer breaks.” While there, he became intrigued by neurosurgery, sensing those specialists were “truly having fun.”

After an internship in general surgery at the University of Pennsylvania Medical Center, Dr. Dilustro completed a residency in neurological surgery at EVMS and a fellowship in cerebrovascular surgery and microneurosurgery at the University of Western Ontario in Canada.

Upon completing fellowship, Dr. Dilustro accepted a position that covered both CHKD and Sentara Norfolk General Hospital. For the next 10 years, he treated both children and adults.

In 1997, his wife, Sharon, was accepted into the master of arts in art history program at the University of Colorado. The family moved to Boulder, and Dr. Dilustro worked at a neurosurgery practice there while she completed her studies. By 2001, he was happy to be back at CHKD for good as one of the expanding health care system’s two first full-time pediatric neurosurgeons. 

CHKD has grown exponentially since then, and Dr. Dilustro has been delighted with its progressive approach to multispecialty clinics. 

He is heavily involved in the hospital’s neuro-oncology clinic, which has embraced advances in chemotherapy and targeted treatments. He also serves as one of the neurosurgeons in CHKD’s spina bifida clinic and has been involved for decades as lead surgeon in CHKD’s craniofacial clinic and its partnership with the medical charity Operation Smile, a relationship that turned CHKD into an international center for craniofacial surgery more than a quarter century ago.

As medicine has advanced during his 30-year career, Dr. Dilustro’s work has grown more complex. In the neonatal intensive care unit at CHKD, babies born as early as 22 weeks now have a chance of survival. However, they are at high risk for bleeding into their brains, which can eventually lead to hydrocephalus and the need for a shunt.  

Pediatric neurosurgeons try to wait until newborns weigh at least 2,000 grams, but even then they have undeveloped immune systems and skin “as thin as tissue paper,” Dr. Dilustro notes. “The risk of infection is so high. You have to be meticulous every step of the way.”

Time spent with neonatal cases got Dr. Dilustro involved in a study of neonatal interventricular hemorrhages early in his career. More recently, he has spoken with an assistant professor of engineering at Old Dominion University who is interested in brain mapping to find the least invasive paths while performing surgery. 

Still, Dr. Dilustro’s heart has always been more in clinical medicine than research.

“We’re involved in every step of these children’s care,” he says. “I have a strong team at CHKD. We recently opened a neuroscience unit for specialized recovery care. I have three superb nurse practitioners, a great office staff, a plethora of health care resources and a great partner. Getting Dr. John Birknes to join our practice was a coup. He had just completed his fellowship at Children’s Hospital of Philadelphia, a perennial powerhouse in pediatric neurosurgery, and I really thought he would opt for the ‘big time.’ His being here is a feather in our cap.”

On the home front, Dr. Dilustro and his wife of 30 years have raised two adult daughters, one a fashion designer and one an architect. He enjoys sailing and boating in his free time, although free time tends to be limited. In fact, he recently sold a boat that was gathering dust. 

“You make sacrifices, yes,” he says. “But you get so much back from the kids.”  

Not surprisingly, the children who grow up more normally – or simply grow up at all – remain forever grateful. The longevity of Dr. Dilustro’s career has even started to play out in clinic: Patients from decades ago now bring in their own sons and daughters to see him.

“Kids I treated 20 years ago contact me to say, ‘Thank you. I was thinking about you. You operated on me when I was 3,’” he relates. “I get Christmas cards from young adults who were once patients and now have children of their own. A woman at a restaurant recently approached me and said, ‘You saved my son’s life 17 years ago.’ Those moments are pretty incredible.” 

William H. McAllister, IV, MD

Riverside Hampton Roads Neurosurgical & Spine Specialists

 

When William McAllister, IV enrolled at the University of North Carolina Chapel Hill, he fully intended to follow in the footsteps of his father, William III, who had studied journalism at UNC.  The elder McAllister worked for The Virginian-Pilot as well as The Washington Post and The Wall Street Journal, and continues writing today.  The freshman’s career goal was specifically sports journalism; medicine was the furthest thing from his mind.

He made a few friends in the pre-med program, but what really attracted him was what he observed on his nightly run after a long day of classes and studying.  “I’d jog at 11 or 12 at night,” he says, “and most of the campus was quiet, but when I ran by the hospital, all these lights would be on, and all these activities would be happening, the helicopter flying in and bringing patients to the trauma center.” He was 18 years old and a night owl, and he remembers thinking, “These people were up and working at the time I felt I was at my best, while my professors and fellow students were sleeping or working in the library.  It was the pulsing energy of the hospital that drew me in.”

He began taking pre-med classes and discovered a natural proclivity for science.  By his junior year, he was doing research in the hospital.  In his senior year, he did an honors project that exposed him to pulmonology, which he first thought might be his specialty.  Then he considered cardiology, then internal medicine – until his first year in medical school, when a lecture about children born with intracranial deformities got him interested in the brain.  His third-year rotation in the neurosurgery service fascinated him, convincing him that he had found his niche. 

He completed his residency in neurosurgery at Loyola University Medical Center and Cook County Hospital in Chicago, and received training in adult spinal deformities at Rush St. Luke’s Presbyterian Hospital in Chicago.  He then completed additional training in neurology at the University of California, San Francisco.

   “It was right around the time that so many breakthroughs in interventional stroke care were happening,” Dr. McAllister remembers, “things like dealing with aneurysms endovascularly through coiling.  UCSF was at the forefront of that technology, so I got to see that aspect of neurosurgery coming into its own.  As a bonus, I got to live in San Francisco during a Chicago winter.”

There were many job offers, but, he says, “I realized my heart was in the southeast, particularly North Carolina and Virginia.”  He means that quite literally, as he met his wife in Chapel Hill, and his own family is from Norfolk.  He went into private practice in Newport News in 2005, and joined the Riverside Health System in 2005.  He’s been a member of the Riverside team ever since.

As part of that team, Dr. McAllister serves as medical co-director of the radiosurgery unit, “where neurosurgery and radiation oncology come together,” he says.  In that capacity, he’s had the opportunity to oversee some of Riverside’s recent technological acquisitions, which have included an update of the Gamma Knife to the Perfexion™ Unit.  The Perfexion™ system has dramatically streamlined workflow and expanded the treatable volume through an automated, multi-source collimator, allowing the surgeons to expand their ability to treat metastatic tumors and other lesions in the brain.  

The unit has lately acquired another update in the concept of stereotactic radiation, a device called a Varian Edge.  “The Varian is delivering radiation that’s more specifically guided by the anatomy of what we’re treating,” Dr. McAllister explains, “so we’re giving more radiation directly to the precise site of the tumor(s).  We need no longer expose surrounding areas, whether the spinal cord, the kidneys or the back of the throat, to radiation.  This completely elevates the level of precision and safety.”

Dr. McAllister recently oversaw Riverside’s purchase of the O-arm 2 – an intraoperative CT scanner used in brain and especially spine surgeries.  The O-arm 2 provides current patient data in real time, in the operating room itself, eliminating the need to send patients to radiology to be scanned.  In addition, he says, “The more complicated spine surgeries require the placement of screws and rods to hold and stabilize the spine.  With the O-arm 2, we’re essentially using a kind of virtual reality to guide the placement of this hardware with greater precision, which allows us to see a picture of the bone as it exists right then.  It’s a way of making these delicate operations safer, and allowing us to do even more complicated procedures.”

Ten or fifteen years ago, Dr. McAllister says, this would have been considered too risky or too time-consuming.  Today, he says, particularly in spine surgery, “the reality is we’re only a few years away from when we’ll do a scan on a patient and then a robot will come in and place these screws while the surgeon watches.  We’re not there yet, but it’s on the horizon.

“At Riverside, we continue to evaluate the newest technological innovations for these delicate brain and spine surgeries,” he says, “but robots will never replace the judgment and skill of a well-trained, seasoned surgeon.” 

As for surgeons like Dr. McAllister, robots notwithstanding, there will still be the satisfaction of making the treatment decision and guiding the actual procedure.  “It’ll be a long time before robots will be sophisticated enough to do some of the more nuanced things we do in the OR.”

Tina C. Rodrigue, MD, MS

Neurosurgical Associates, Norfolk; Staff Neurosurgeon,  Sentara Norfolk General Hospital

 

After two decades as a general neurosurgeon, Dr. Tina Rodrigue’s sense of wonder is still obvious when she discusses the intricacies of the nervous system. Her favorite work is perhaps the most delicate and dangerous: extracting tumors from the brain, pituitary gland and more rarely the spinal cord. 

“These procedures are so elegant, so clean and precise – unlike any other kind of operation,” Dr. Rodrigue says. “They’re fascinating, and in so many cases, you can really help people improve their quality of life.” 

The evolution of minimally invasive techniques has allowed Dr. Rodrigue to help even more patients in recent years, whether they are battling debilitating neurological deficits such as speech impairments or hemiparesis or, at times, facing steep odds of survival. 

One such brain cancer patient has called her every year, on the exact anniversary of his complex surgery, to thank her. One of her current patients is married to another man whose life she saved several years ago, by removing an arteriovenous malformation akin to an aneurysm.  

“She told me, ‘You are the reason why my husband is here. I wouldn’t go to any other doctor,’” Dr. Rodrigue relates. “Those words mean so much to me. This is a challenging specialty, but it’s very rewarding.”  

Neurosurgeons increasingly can disturb less healthy brain tissue thanks to endoscopic equipment and computer-guided imaging systems that precisely pinpoint abnormalities even deep inside the brain. In addition, pituitary tumors and some skull base tumors now can be removed through sinus cavities rather than the skull. 

In spinal surgery, minimally invasive procedures similarly have led to smaller incisions and shorter recovery times. Dr. Rodrigue also is excited about research into motion preservation technology, which could substitute durable, implanted artificial discs between vertebrae for spinal fusions. 

“The spine is not meant to be fused, even if the surgery can resolve a trauma or instability,” Dr. Rodrigue notes. “Spinal fusion now is fairly overused for chronic pain. If we can recreate the natural anatomy of the spine and preserve motion between segments, we should be able to achieve better results for many more patients. My hope is that in 20 years or so, we may not be doing spinal fusions at all.” 

Dr. Rodrigue, now 47, was interested in anatomy in elementary school. Growing up about an hour north of New York City, she had three dream jobs as a child: doctor, movie star or President of the United States. To encourage the first profession, Dr. Rodrigue’s mother brought home coloring books detailing internal body structures and introduced her to what would become her favorite book, “I Am Joe’s Body”, a narrative on organs and systems. The young girl soon memorized it from cover to cover. 

As a teenager and then an undergraduate at Colgate University, Dr. Rodrigue originally planned to go into psychiatry. She sought to understand how the mind could affect behavior – specifically, she wanted to figure out how to stop serial killers. Yet she found she was drawn more to biology and anatomy than to theory, and she soon pivoted to a neuroscience major. 

From there, neurosurgery was a logical next step in medical school. Dr. Rodrigue paid for her degree at Medical College of Virginia by joining the United States Navy, as her parents couldn’t afford to cover both that and her younger brother’s college tuition. 

Praised by colleagues for her selfless nature and lack of ego, Dr. Rodrigue doesn’t sugarcoat her initial fears about becoming a brain surgeon. She willingly reveals that she fainted repeatedly during an early obstetrics rotation, but she thrived in neurosurgery, especially after a nurse gifted her with a pair of compression stockings to get through long surgeries. 

“I don’t need those anymore, although my ankles get pretty swollen after standing for hours,” she says with a laugh. “I was always fascinated by these cases, including the emergency setting that came along with so many of them.”  

Dr. Rodrigue completed her internship and residency at University Hospitals of Cleveland and also earned a Master’s in Clinical Investigation at Case Western Reserve University before moving to Hampton Roads in 2004. She served for three years at Naval Medical Center Portsmouth, where she was named Staff Physician of the Year for the academic year 2005-06.  

Following her Navy commitment, Dr. Rodrigue worked in private practice with both adult and pediatric patients before joining Neurosurgical Associates in 2014. She has been on staff at Sentara Norfolk General since 2007, the same year she became an American Board of Neurological Surgery Diplomate. In addition, she is a member of the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the North American Spine Society.  

The majority of Dr. Rodrigue’s cases today are spine patients, with ruptured discs, degenerative spinal processes and traumas among the most common complaints. She handles a smaller amount of neuromodulation cases as well. 

At home, Dr. Rodrigue and her husband, Todd, are parents of two teenagers and also have fostered several children over the past five years, ages 3 to 16. She credits her love of service to her parents, who frequently lent a hand to people going through tough times and took in stray or injured animals.  

Of course, Dr. Rodrigue can’t help everyone, which she says is the hardest part of her professional life.  

“Sometimes, the severe neurological deficits will remain even after treatment, or there’s simply nothing we can do to save someone’s life,” she says. “Yet more and more, I am grateful and amazed by what we can do.”

Linda Jones-Brandon, FNP-BC

Internal Medicine and Nephrology, Certified Clinical Research Professional,
Peninsula Kidney Associates 

 

Caring for kidney failure patients isn’t an easy task. A surprising number are very young, and non-compliance and depression are common. Many are facing multiple health complications associated with chronic kidney disease, including an increased risk of heart attack or stroke. 

Linda Jones-Brandon, a nurse practitioner and researcher at Peninsula Kidney Associates for nearly 18 years, embraces all of the challenges.    

“In my heart, I believe that nursing is truly a calling,” Jones-Brandon says. “Serving a chronically ill population is not for everyone, but my patients deserve quality care, compassion and empathy. Sometimes I am able to get through to people when the doctors can’t, often because I just spend more time with them.”  

A Newport News native, Jones-Brandon is charged both with educating her patients on medications and lifestyle therapies and – perhaps just as importantly – encouraging them to stay positive. 

“Some people view their diagnosis as a death sentence,” she notes. “It’s very difficult to watch some patients deteriorate because they’re not taking care of themselves. My job is to give them hope: to boost their spirits, counsel them and connect with them as individual human beings.” 

Jones-Brandon, who earned her nursing degree from Old Dominion University in 1996, originally gravitated to critical care. While managing cardiac and post-surgical patients, she also had to support some through hemodialysis. “I was always fascinated,” she recalls. “I would just stand there watching the process of a dialysis treatment and asking a ton of questions.”  

After completing her master’s degree in nursing at Hampton University in 2000, Jones-Brandon dove into nephrology, a field where nurse practitioners are playing an increasingly important role. By 2004, she started getting involved in clinical research studies at Peninsula Kidney Associates; today, she serves as Lead Study Coordinator for the practice’s thriving Clinical Research Program. 

In that role, Jones-Brandon has helped gain FDA approval for multiple medications for renal disease, including treatments for anemia, hypercalcemia and other mineral and bone disorders. “It’s a lot of hard work, but it’s extremely rewarding to increase the options for these complex patients,” she says.  

In addition, Jones-Brandon is passionate about removing roadblocks within the healthcare system that can thwart early diagnosis of kidney disease. 

“I see far too many young people on dialysis, especially African-Americans,” she relates. “There are socio-economic and insurance factors that keep people from getting regular checks of their blood pressure and urine protein levels. By the time they feel sick enough to go to the emergency room, they may be in full-blown kidney failure.”  

Furthermore, some patients who undergo a kidney transplant discover they can’t afford needed post-surgical medication and end up back on dialysis: “Sometimes I have to talk to them about finances and ways to plan. They don’t always like it, but I do it because I care about them.” 

Jones-Brandon encourages a message of disease prevention throughout different specialties, especially family medicine. Maintaining an optimal weight, eating well, drinking plenty of water, exercising and scheduling annual physical exams are all critical to kidney health, she notes. So is strict management of high blood pressure and diabetes, even if they are symptomless.  

“Primary care physicians are getting more proactive about referring people to nephrologists sooner, which I think is a very important trend,” she adds. 

A married mother of two preteen boys, Jones-Brandon enjoys flower gardening as a hobby at her Smithfield home and counts herself blessed to have built a career she loves – especially in her hometown. 

“I’m always learning, and I work with great doctors,” she says. “I have a very collaborative, open relationship with them, which helps build stronger connections between them and our patients. I’m grateful that people have trust in me.”

HAMID R. OKHRAVI, MD

Director, Memory Consultation Clinic, Glennan Center for Geriatrics and Gerontology at Eastern Virginia Medical School; Associate Professor, EVMS

 

To Dr. Hamid Okhravi, the Alzheimer’s Association is a critical partner in research, education and support for patients and caregivers facing a diagnosis of dementia. Volunteering for the organization’s Southeastern Virginia Chapter, then, is an easy choice. 

Since arriving at Eastern Virginia Medical School in 2010, Dr. Okhravi has served on multiple medical and scientific committees and spoken regularly at community forums and fundraising and media events. All the while, he is treating patients and conducting research at EVMS’ busy memory clinic.   

“Hopefully, we will one day have a cure for dementia,” he says. “But even right now, there is so much we can do to help patients – from making an accurate diagnosis to teaching caregivers how to manage emotional, physical and financial challenges.”

As many as half of all dementia cases go undiagnosed by physicians, about a third of caregivers lose most or all of their life savings, and nearly every patient develops neuropsychiatric symptoms such as depression, apathy, agitation, hallucinations or delusions. All can contribute to caregiver depression and nursing home placement. 

When Dr. Okhravi lectures to physicians and residents, he has one constant piece of advice: “I tell them, ‘The best thing you can do for these patients and their caregivers is to refer them to the Alzheimer’s Association.’ They can find support in so many different areas.” At his sessions for the general public, question-and-answer sessions can easily stretch an hour.  

A native of Iran, Dr. Okhravi and his three sisters – all doctors – grew up idolizing an uncle who was an orthopedic surgeon. After graduating from Mashhad University of Medical Sciences in Iran, he did an Internal Medicine residency at St. Louis University and then Hurley Medical Center at Michigan State University, followed by a Geriatrics fellowship at the Mayo Clinic in Minnesota. There, he worked with Dr. Ronald Petersen, a national leader in the field of Alzheimer’s disease. 

“I always found geriatrics to be fascinating, challenging and fulfilling,” he relates.  

Over the past eight years, EVMS’ Memory Consultation Clinic has grown from seeing patients a half day a week to offering daily slots. Dr. Okhravi also recently collaborated with the Alzheimer’s Association to create a new caregiver support group attended by 30 people a month. 

Meanwhile, his research has drawn local patients into promising trials. For example, Dr. Okhravi was a site principal investigator on the Imaging Dementia – Evidence for Amyloid Scanning (IDEAS) Study, a nationwide study that next year will publish a report on the clinical usefulness of brain scans to detect plaques. About 75 of his patients from Hampton Roads were among 18,000 enrolled.   

EVMS and Old Dominion University now have partnered to develop wearable sensors that could detect oncoming agitation in patients, by monitoring subtle shifts such as increased heart rate and breathing or limb movements. The sensors then could alert caregivers or even link to a digital assistant to play soothing music or display old photographs. 

“We’re so lucky to have Dr. Okhravi here,” says Katie McDonough, Director of Programs & Public Policy for the Alzheimer’s Association’s regional chapter. “In addition to his research, he somehow makes himself available anytime we ask him. He’s one of our biggest champions.”  

Dr. Okhravi, in turn, credits Alzheimer’s Association advocacy for boosting federal research funding, which he believes will produce therapies to modify the disease process within a few years. In his eyes, the more families that turn to the organization, the better.     

“I’ll do anything I can to educate people, ease their stress and direct them to the right resources,” he says. “Honestly, that’s one of the most rewarding parts of my job.”

Throughout Hampton Roads, there are physicians who regularly volunteer their time, knowledge, training and experience to individuals and organizations in this community, in the nation and throughout the world.  They do so quietly, without fanfare, and often without reward or recognition of any kind.  Hampton Roads Physician is pleased to acknowledge these physicians by sharing their good deeds with our readers.

New Options in IVF

How INVOcell is changing infertility treatment

 

Over the past 40 years, in-vitro fertilization has become more and more reliable through genetic testing, intracytoplasmic sperm injection, continuous video microscopy of developing embryos, and many other technologies.

But a new technique hopes to achieve successful pregnancies without those techniques and tests, without an incubator and without many of the steps and drugs that make IVF so expensive.

INVOcell™ is an infertility treatment that gained FDA approval in 2015. The small plastic device allows for fertilization to occur within the vagina. Since the vagina is the correct temperature and pH to keep both sperm and eggs alive, the technique doesn’t need a temperature-controlled lab or a lot of specialty equipment.

Gerry Celia, PhD

“INVOcell was originally geared to the extreme rural markets like those found in many African and South American countries,” says Gerry Celia, PhD, director of the IVF Laboratory at EVMS Jones Institute for Reproductive Medicine. “These countries don’t have the infrastructure to support a lab.”

The procedure also requires fewer lab technicians and experts, which can be hard to attract to a rural town, and costs less, helping people who may not be able to afford IVF. Though the process is similar to IVF, it involves fewer tests and much less equipment and was not meant to replace IVF procedures in places where patients have access to modern resources. 

The INVOcell Process
The INVOcell process begins with mild ovarian stimulation. However, since only about 7 embryos can fit into the device, the patient uses fewer stimulation drugs than with traditional IVF. This is the first place where couples typically save money. By using fewer drugs, they can potentially save thousands of dollars.

Next, the eggs are retrieved and sperm collected. A physician or lab technician inserts them into the INVOcell device, which a physician places in the woman’s vagina. The device is held against the cervix with a diaphragm device for three to five days, allowing fertilization and early embryo development to occur. This is another time where couples may save money. They won’t need to pay lab costs to store and monitor the sperm, eggs and early-stage embryos.

“Incubation of the INVOcell in the vagina mimics what we do in an incubator,” says Dr. Celia.

When the couple returns, the best embryos are selected for transfer. Just like IVF, the couple then needs to cross their fingers and hope an embryo implants.

Early results show that INVOcell achieves similar rate of pregnancy as traditional IVF treatment in women who have a high chance of success. This includes women under the age of 38 with normal ovarian reserve, a body mass index below 36 and a partner or donor with good sperm parameters.

Robin Poe-Ziegler, MD, FACOG

“The INVOcell cycle is dramatically less expensive than an IVF cycle, but our pregnancy rates are very similar,” says Robin Poe-Zeigler, MD, FACOG, Medical Director of the New Hope Center for Reproductive Medicine. Her practice began offering INVOcell in June 2017. “It’s really opened an avenue of conception for patients who previously were not able to afford an IVF cycle.” 

The Cost of Lower Costs
Though INVOcell works as well as IVF for that specific population, it’s currently unclear how well it works for other women who may face more challenges in achieving pregnancy. Because INVOcell leaves out so many steps of IVF, physicians could miss out on important diagnostic information.

Through traditional IVF, the eggs and sperm undergo a fertilization check the day after they are combined. This fertilization check is not typically used with INVOcell, as it could put the embryos at risk. If the device has no embryos in it at the end of three or five days, it’s not possible to know whether fertilization failed or embryo development failed. 

INVOcell also takes away the ability to monitor embryo development over a five-day incubation period. 

“In a modern IVF laboratory, we can see the embryo develop in real time through continuous video microscopy,” says Dr. Celia. “Watching that development tells us a lot about how that embryo is growing and whether it is normal or abnormal. An embryo that fertilizes abnormally, and therefore has chromosomal abnormalities, can have normal morphology on day three or day five.”

The FDA approved only a three-day incubation period for INVOcell, though five days of incubation is preferred. Five-day incubation gives embryologists and physicians time to see how healthy the embryo is. The change to a five-day incubation periods around 2008 led to a rise in success rates of IVF.

“Embryos can develop through day three just by being fertilized,” says Celia. “After three days, they can fail due to the genetics contributed by the egg or sperm. We follow them through day five and six of development, which allows a much greater ability to select a good embryo from a bad embryo.”

INVOcell also doesn’t include genetic testing. For many couples, this may not be an issue. But for families with genetic conditions like cystic fibrosis or Tay-Sachs disease, or advanced maternal age where diseases such as Down syndrome become a concern, this testing can be incredibly important.

While taking away these tests does make INVOcell much cheaper, Dr. Celia fears it could also put some couples at a higher risk of failure than IVF, adding costs and prolonging infertility treatment. Compared to other low-cost options that include monitoring embryo development, INVOcell leaves clinicians in the dark when a cycle fails. He also warns it could be a couple of years before the data is available on how effective the procedure is in many different populations of women.

In the end, Dr. Celia also says INVOcell could end up raising the price of IVF for women who choose that procedure if they are anything less than ideal candidates.

“It is important to realize that there is no difference in operating costs or personnel costs when INVOcell is used in a modern IVF clinic. The potential savings come from using minimal stimulation protocols, which are already offered at The EVMS Jones Institute and most other IVF centers in the United States,” says Dr. Celia. “When these options are available at a similar cost to the patient, but with the advantage of modern IVF technology, there may not be a benefit to using INVOcell.”

A Hybrid Solution
Many practices allow patients to add back in some testing or other procedures while still using the INVOcell device for incubation. While these changes in protocol may raise the price, they may also improve chances of success for certain patient populations.

“We’ve used INVOcell with patients in their 40s, in patients using intracytoplasmic sperm injection because of male factor infertility; we’ve used it for all different types of patients,” says Dr. Poe-Zeigler.

The first couple from the New Hope Center to have a baby using INVOcell was a lesbian couple in a co-IVF cycle. The device allowed both partners to be more involved with the pregnancy. One partner provided the eggs and used the INVOcell device while the other partner had the embryos transferred into her uterus. Both partners got to carry the baby, at least for a short time.

Like many practices, the New Hope Center will also perform genetic testing on embryos before implantation and will freeze any excess embryos for possible IVF cycles in the future. Though these services were not originally intended to be part of the INVOcell process, they do allow patients more flexibility in their treatment.

Even with these extra tests, INVOcell remains cheaper than IVF. Many couples see it as an opportunity to complete two cycles for the price of one. Other couples enjoy the peace of mind of keeping their embryos with them throughout incubation instead of leaving them in a lab.

Though the final verdict on INVOcell may be years away, when more information on success rates is published, patients seem to have made their decision about this technology.

“It’s incredibly popular,” says Dr. Poe-Zeigler. “Couples can use reproductive technology at almost half the cost and still get the same success rates. At our practice, we now have more patients requesting INVOcell than IVF.”

The Challenges of Alzheimer’s and Dementia Care

How research is helping health professionals find solutions

 

Unless a new treatment for dementia is discovered soon, an estimated 7.1 million Americans will be living with Alzheimer’s disease by 2025. By 2050, that number will explode to 13.8 million, which could be disastrous for the U.S. healthcare system and devastating for communities across the country.

Research is providing new insights into the disease and its far-reaching effects on patients and families. From targeted medicines to dementia care best practices, health professionals are looking for new solutions to help slow the coming catastrophe.

Adel Aziz, MD

Targeted Treatments Show Some Promise
Pharmaceutical companies have spent millions of dollars to uncover a drug to treat dementia with no success so far. However, Dr. Adel Aziz, neurologist at Riverside Neurology Specialists, says new treatments introduced at this year’s Alzheimer’s Association International Conference show promise at targeting the biochemical causes of dementia.

One treatment, crenezumab, uses antibodies to target beta amyloid protein. A build-up of this protein in the brain is associated with dementia. 

“A phase II trial showed promising effects of clearing the amyloid protein,” says Dr. Aziz. “Measures of cognition improved in several subsets of the study, and 75 percent of the study population saw a clinical benefit.”

Gilbert Snider, MD

Dr. Gilbert Snider, neurologist at Chesapeake Regional Healthcare, also believes the lymphatic system of the brain will play an important role in upcoming research into dementia.

“Up until a few years ago, it was thought the brain didn’t even have a lymphatic system,” says Dr. Snider. “It is a hidden system in which fluid is extruded through microscopic arterioles, filters through the brain, carrying toxins and impurities with it, and is taken up by both the venous system and a recently discovered lymphatic system in the meninges.”

Dr. Snider says the lymphatic system and vascular system of the brain flush away poisons and toxins. But as the vascular system deteriorates with age, it allows more amyloid protein to build up. Since the lymphatic system cannot take on the extra load, it, too, begins to fail, leading to more and more protein. 

One study on mice shows promise for improving the lymphatic system in the brain.

“Vascular endothelial growth factor that is secreted by the blood vessels helps develop the lymphatic system better,” says Dr. Snider. “It can actually reverse dementia in mice if it is administered early in the disease process.”

Earlier Diagnosis for More Effective Treatment
Diagnosing Alzheimer’s disease early may be the real challenge. People with dementia likely have the condition ten to twenty years before the first signs are detected.

“A dementia diagnosis can easily be missed because it usually starts slowly and affects the patient’s personal life,” says Dr. Aziz. “It needs to be detected first by people around the patient and brought to the attention of the primary care physician.”

Even if spotted very early, the disease may have progressed too far in these patients for treatment to be effective. Dr. Aziz believes that’s why so many clinical trials fail in phase III.

“Those studies targeted people who already have Alzheimer’s or dementia,” says Dr. Aziz. “It’s possible that clearing the brain of amyloid proteins won’t make a difference because the damage has already happened. But if we target that protein in earlier stages, when there are no symptoms or symptoms are very mild, these studies may succeed.”

Current methods of diagnosing Alzheimer’s in pre-clinical stages are expensive and difficult. Physicians can spot biomarkers of the disease through a spinal tap or PET scans. Newer PET scans can use tracers that target amyloid proteins, but the tracer has a short life of only 20 minutes. Neither of these tests can be used on a large scale to provide early diagnosis for the millions of Americans who likely already have the condition.

Many researchers are working to create a reliable scale to determine someone’s risk for Alzheimer’s disease. These scales target people between age 40 and 60 who may not have clinical symptoms, but who have the biomarkers for dementia. Someone who may be at high risk for the disease can learn about lifestyle factors that may help them prevent or delay dementia onset.

“There is hope that by targeting this population, we can impact the trajectory of this national catastrophe,” says Dr. Aziz. 

Lifestyle Factors for Prevention
While no medicine can currently prevent Alzheimer’s disease, a heart-healthy lifestyle can benefit the brain and reduce a patient’s risk for dementia. Some studies suggest that age-specific risks for Alzheimer’s disease may actually be falling thanks to control of cardiovascular risk factors.

Managing cardiovascular risk factors such as high blood pressure, high cholesterol, or diabetes are obvious first steps in preventing dementia, along with moderate exercise and a Mediterranean diet. 

But Dr. Snider says other lifestyle factors can also play a role in lowering dementia risk. Socialization and continued learning are key to building up cognitive reserve to help resist the effects of neurological damage.

Quality sleep is also vital for preventing Alzheimer’s disease and dementia, Dr. Snider says, since the lymphatic system works best when you are asleep. If patients suffer from sleep apnea or other sleep disorders, proper treatment may lower their risk for dementia in the future.

Ongoing Care for Changing Needs
Early in the disease, these lifestyle changes may temporarily help reduce or slow symptoms. However, as the disease progresses, patients have growing and changing needs in all aspects of their lives. Dr. Aziz says current healthcare practices are not set up to properly address these needs.

“Dementia is associated with other conditions like depression, risk of falls and medication misuse,” says Dr. Aziz. “We need to introduce Centers of Excellence for Alzheimer’s and Dementia Care and propagate those centers around the county to ensure physicians can address these needs.”

Jacob Almeida, MD

A dementia diagnosis also impacts what medical care a patient should receive. Dr. Jacob Almeida, geriatrician with TPMG Peninsula Internal & Geriatric Medicine, says once patients have an Alzheimer’s diagnosis, all other comorbidities need to be handled in that context.

“Life expectancy is about three to 12 years after diagnosis,” says Dr. Almeida. “The burden of multiple treatments can cause significant harm and decrease longevity. Patients, caregivers and physicians need to discuss goals of care as early in the disease process as possible, so the person with the condition can weigh in on decisions.”

Establishing best practices for dementia care through Centers of Excellence may help improve quality of life for both patients and caregivers.

Care for the Caregiver
Unpaid caregivers, typically a spouse or a child, bear the brunt of care for patients with dementia. These caregivers deliver an estimated $232 billion worth of unpaid care each year and carry a heavy financial, emotional and physical burden when providing care with often little support.

“We have very limited services outside of the home, aside from the Senior Services of Southeastern Virginia and Peninsula Agency on Aging,” says Dr. Almeida. “We also have very few adult daycare or day programs in Hampton Roads that offer respite care.”

Though caregiving at home relieves pressure on the healthcare system, it adds to the growing cost of dementia care. Caregivers may miss work or even quit working completely to provide care for loved ones. They also face significant health concerns as a result of caregiving; 30 to 40 percent of caregivers experience depression, and 35 percent of caregivers report a decline in their health as a result of caring for Alzheimer’s patients.

“Patients do best at home when there is adequate support from family or paid caregivers,” says Dr. Almeida. “But when that burden becomes so great that there is caregiver breakdown and the care of a loved one is impeding on the caregiver’s health, it’s time to consider other options such as assisted living.”

Giovanni Montague-Sneed, MS, RN

Giovanni Montague-Sneed, MS, RN, Senior Vice President of Resident Care at Commonwealth Senior Living, says that earlier referral to residential communities, before a caregiver reaches a point of crisis, better benefits both caregivers and patients.

“When placement in an assisted living community is introduced earlier, the services provided to a resident with Alzheimer’s or dementia can be augmented with specialized memory care services to include specialty trained caregivers, cognitive therapies, programming based on the cognitive function of the individual, expressive art therapy, as well as other plan of care intervention,” says Montague-Sneed. “Supportive living in an assisted living or memory care neighborhood that is fully licensed to care for individuals through all phases of the disease allows the resident to continue to have meaningful relationships with family members and peers as they progress through the disease.”

Montague-Sneed says earlier referral can help patients better participate in their care, whether it is lifestyle changes or music therapy. It also gives both patients and caregivers an opportunity to learn coping skills and improve their communication skills.

“We need to support caregivers and help them understand the dementia process so they don’t wait for their own personal health failures before looking for a residential option for their loved one,” says Montague-Sneed. 

She says families should research care options before that level of care becomes necessary and encourages caregivers to seek out residential options that have specialized dementia care. Some long-term care facilities and nursing homes are equipped to handle acute care needs but may not offer the support that patients with dementia need. Making an early decision about which care environment a patient needs allows families to anticipate future care, involve the patient in the decision, and avoid rushing the decision.

“Researching care options before the need is imminent helps families feel more confident in their decisions and has been found to lessen the need to transfer a loved one after initial placement,” says Montague-Sneed. 

Whether at home or in an assisted living facility, patients with Alzheimer’s disease or dementia need intensive support to stay safe and healthy. With earlier diagnosis and intervention, a focus on prevention, and more support for caregivers, health professionals may be able to ease the demand of dementia care on the healthcare system long enough to avoid a crisis and uncover a more effective treatment.

 

 

Introducing the UroLift® System for Men with BPH

Benign Prostatic Hyperplasia, or BPH, affects over 40 million men in the United States.1 The condition can cause bothersome urinary symptoms that can worsen with age. Most noticeably, men may have a frequent need to urinate, weak or slow urinary stream, incomplete bladder emptying, difficulty or delay in starting urination, urgent feeling of needing to urinate, and a urinary stream that stops and starts. 

Traditional treatments include the use of alpha blockers which can cause unpleasant side effects including dizziness, headaches or sexual dysfunction. And some men may not get adequate relief of their symptoms with this class of medications.2

Surgical options include transurethral resection of the prostate (TURP) or photovaporization of the prostate (PVP). However, these options typically require general anesthesia, overnight hospitalization, and post-operative catheterization. Surgery can also increase the risk of erectile dysfunction or loss of ejaculation.2

TPMG Urologists Dr. Kostiner, Dr. Habibi and Dr. Darby, are excited to offer our patients the Prostatic Urethral Lift procedure using the UroLift® System. The FDA-cleared UroLift System is a minimally invasive procedure to treat the symptoms of BPH that does not require any cutting, heating, or removal of prostate tissue.

Here’s how it works: our Board-certified urologists use the UroLift System device to lift and move the enlarged prostate tissue out of the way so it no longer blocks the urethra. Tiny implants are placed to hold the tissue in place, like tiebacks on a window curtain, leaving an unobstructed pathway for urine to flow again.

Robust clinical data continues to support the UroLift System as the new standard of care for men with BPH. An ongoing multi-center, multi-national real-world study of more than 800 UroLift patients found that the UroLift System offers significant improvement in symptoms and quality of life through 24 months.3 

Highlights of the study include3:
With a 40% reduction in IPSS score at 24 months, results were consistent with the data from the randomized, five-year L.I.F.T. study. L.I.F.T. demonstrated that the UroLift System treatment provides a highly tolerable minimally invasive procedural experience, rapid reduction of symptoms after the procedure, and sustained improvements in QoL (Quality of Life) score, IPSS (International Prostate Symptom Score), and Qmax (peak urinary flow rate), while preserving sexual function.

The registry retreatment rate was consistent with L.I.F.T., which demonstrated a retreatment rate of just 2-3% per year, comparing well to the 1-2% expected rate for the gold standard TURP.

Additionally, the registry included patients in urinary retention prior to treatment.  Of those with follow up data, 96% were able to urinate without use of a catheter within the first month. 

The registry will continue to enroll additional sites and is expected to increase to more than 2,000 patients.

Recently, the FDA cleared new indications for the UroLift System, making patients who have an obstructive median lobe and those as young as 45 now eligible to receive treatment with the UroLift System for their BPH symptoms.

If you have patients who are interested in learning more about this treatment option, visit MyTPMG.com 

References
1Berry, et al., J Urol 1984 and 2013 U.S. Census worldwide population estimates

2AUA Guidelines 2003

3Keyes, EAU 2018, Copenhagen

MAC00827-01 Rev A

Indications of Sciatica in a Physical Exam

By Rebecca Shoemaker, MD, Hampton Roads Orthopaedics & Sports Medicine

 

Sciatica is a descriptive term that refers to radiation of pain from the lower back down the back of the thigh and leg in the distribution of the sciatic nerve. A true sciatica describes irritation of the six nerve roots that comprise the sciatic nerve. When sciatica originates from these roots, there may be key findings indicative of radiculopathy on a physical exam. 

For an L5 or S1 radiculopathy, there may be a positive straight leg raise or crossed straight leg raise in a supine position. In a seated position, there may be a positive Bechterew or slump test. Cervical flexion may also reproduce the pain, as it causes traction of the dura, lumbosacral nerve roots and sciatic nerve. 

In the presence of an S1 radiculopathy, motor testing may discover weakness in the ankle plantar flexors and hip extensors, along with a decreased or absent Achilles reflex. In the case of an L5 radiculopathy, there also may be weakness in the ankle dorsiflexors, inverters and everters, hip abductors or extensor hallucis longus, as well as a decreased or absent patellar reflex. 

Although facet arthropathy generally does not extend past the knee, it can refer pain down the posterior thigh and even into the leg. More often, the patient will experience worsening pain with extension and facet loading, as opposed to a patient with discogenic pain who will frequently complain of increased pain with lumbar flexion.  

Piriformis syndrome is a rare condition that causes pain in the distribution of the sciatic nerve. It may occur due to muscle hypertrophy, fibrosis following trauma or anatomical anomalies involving the nerve roots. The patient may have pain with sitting due to weight bearing on the buttock, a positive piriformis test, or pain with palpation at the lateral margin of the sacrum. 

There are a few other conditions that can mimic sciatica yet occur outside the lumbosacral spine. Sacroiliitis can present as pain localized to the low back or buttock, but it also can refer pain laterally along the waistline, into the groin and hip and down the posterior or lateral thigh. While the pain usually stops at the knee, it can extend into the lateral or posterior leg. The patient may have tenderness with palpation to the posterior superior iliac spine, positive distraction, thigh thrust or compression test, Gaenslen’s test or a positive FABER test contralateral to the pathologic side.

Bursitis also may refer pain down the leg: trochanteric bursitis down the lateral thigh, and ischial bursitis down the posterior thigh. In the case of refractory trochanteric bursitis, an underlying piriformis syndrome is a possibility given the insertion of the piriformis muscle on the greater trochanter.

The mainstays of treatment for all of these conditions are conservative and include rest, physical therapy, non-steroidal anti-inflammatory drugs and oral steroid tapers. Resistant cases may respond to steroid injections. 

In the event of radiculopathy with weakness, sensory changes or pain not alleviated by conservative measures or epidural injections, referral to a surgeon may be appropriate. Additionally, early surgery may be warranted in the case of nerve root compression with severe weakness.

Dr. Shoemaker specializes in interventional pain management and physical medicine and rehabilitation at HROSM. She is Fellowship trained in Pain Medicine. hrosm.com

Compliance 101: Employment Agreements for Healthcare Providers

By Erica Pero

 

It’s time for a refresher in drafting a compliant employment agreement for a healthcare professional. Here are five things to include:

Assignment of Billing Rights.
If you’re going to bill third party insurance for services provided by the healthcare professional through your practice, make sure that your employee assigns his/her right to bill insurance payors to your practice. This way you have legal permission to bill on his/her behalf.

No Excluded Providers.
Make sure your employee warrants that he/she is not an “Excluded Provider” (someone prohibited from billing for Medicare services) and that they must tell you if they become an Excluded Provider during the course of employment. (Check the OIG website before making a job offer to confirm that they’re telling you the truth!) There are stiff penalties for employing an excluded provider and it’s easy to avoid doing so!

Reasonable Non-Compete.
Most states only enforce reasonable non-compete provisions, meaning that if you draft an unreasonable non-compete, a court will either revise it or throw it out completely (yikes!). Don’t overreach! Instead, limit competition only to the extent that you protect your legitimate business interests. If your practice draws the majority of patients from within a five mile radius of your office, don’t prohibit the employee from finding employment within 15 miles of your practice!

Clear Compensation Calculation.
Make sure that both you and the employee understand the compensation calculation, and then stick to it. The books should match what the Employment Agreement says. If you’re unsure, ask a CPA to audit your payroll.

Malpractice Insurance Coverage.
It’s helpful to state who is paying for malpractice insurance coverage in the following instances: (1) tail coverage for employee’s previous job, (2) coverage for employee’s current role at your company, and (3) tail coverage once he/she no longer works for you.

A properly drafted Employment Agreement is helpful in avoiding inadvertent fraud and provides a framework for success. If you have further questions, contact a health law attorney.

Erica Pero, an attorney with Pero Law, focuses her practice on health law. She helps healthcare professionals navigate the complexities of running a business in today’s healthcare industry. Pero Law is a lean law firm committed to excellent customer service and exceptional legal representation. perolaw.com