April 22, 2018

Ray T. Ramirez, MD, FACS, FASCRS

Colorectal Surgeon, Chesapeake Surgical Specialists, Chesapeake Regional Medical Group

 

About a third of all colon surgeries in the United States are now done minimally invasively, while two-thirds of patients still must undergo open procedures.

Dr. Ray Ramirez has dedicated much of his career to flipping those figures. By training surgeons, residents and medical students nationwide in less invasive methods that he has developed, Ramirez hopes the majority of future patients will find themselves on the less grueling side of the equation.

“Put simply, my goal is to save more people from big operations,” he says. “Often, we can get the same results with much less pain and recovery time, shorter hospital stays and a significantly reduced risk of permanent complications.”

Ramirez, a second-generation colorectal surgeon, specializes in complicated cases of the small intestine, colon and rectum. A nationally-recognized expert on procedures such as hand-assisted colon resection and sphincter-sparing surgery, he often is among the first physicians to test advanced technology in the operating room. His peers, along with local and national publications, have named him a top doctor on numerous occasions.

Laparoscopic procedures on the colon can be difficult to perform because – unlike with an operation such as gallbladder removal or hysterectomy – surgeons often need to enter multiple regions of the abdomen on a single case, Ramirez notes. To help, he has developed a system that standardizes the locations of incision and trocar sites. “This takes a lot of variability out of the equation, so it is more reproducible,” he explains. “It is simpler to teach, and to learn.”

For patients with low rectal cancers, sphincter-saving minimally invasive surgery aims to preserve muscle function in the anal canal and opening, thus avoiding a permanent colostomy bag. “Once these patients are fully recovered, they almost always can go to the bathroom normally,” Ramirez says. “Obviously, that is quite important to their quality of life.”

Ramirez also has embraced laparoscopic-assisted colonoscopy for removal of complex colon polyps, which lowers the risk of colon perforation and dangerous bleeding. By placing a laparoscope into the abdomen and a standard colonoscope into the colon at the same time, he can visualize the intestine from both the outside and inside. “If we do any damage while removing polyps, we can fix the problem immediately,” he says.

Ramirez had big shoes to fill as a doctor: his father and role model, Dr. Renato Ramirez, was a prominent local colorectal surgeon. Ramirez was born when his dad, now retired, was completing a fellowship at the Mayo Clinic; the family moved to Hampton Roads shortly afterward. The son knew he wanted to be a surgeon, too, and the challenges and rewards of his father’s specialty appealed to him.

“You’re doing a lot of complex intra-abdominal surgeries, hopefully curing people of colon cancer,” he says. “And just in general, people who have anorectal problems – issues such as hemorrhoids and abscesses – are very miserable. When you can make them better, they are very, very grateful. I get a lot of hugs at work.”

After graduating from the University of Virginia, Ramirez completed his medical degree and general surgery residency at Eastern Virginia Medical School. He followed that with a colon and rectal surgery fellowship at Alton Ochsner Medical Foundation in New Orleans. He then had a chance to practice with his father for several years in Chesapeake: “It was great because we taught each other different skills. My dad didn’t do minimally invasive surgeries, for one, which forced me to get very proficient at them.”

Ultimately, Ramirez became so proficient that Ethicon, a subsidiary of Johnson & Johnson that develops surgical systems and instruments, asked him to become a teaching consultant. He now gives two-day courses on minimally invasive techniques to general and colorectal surgeons across the country, including lectures, videos and observation in the operating room. Ramirez also works with residents and students at Portsmouth Naval Hospital and EVMS. “The more people that are trained, the more cases we can hopefully get done this way in the future,” he says.

Beyond technology, Ramirez has discovered a good bedside manner is critical when socially embarrassing problems are involved. He also has gained insights from being on the opposite side of the doctor-patient relationship, as his mother-in-law died of rectal cancer.

“I try hard to make my patients feel comfortable – to put myself in their chair and treat them how I’d want to be treated,” he says. “I don’t use medical jargon. I want them to understand what’s happening to them and how I can help.” He uses that same plain talk in the free community seminars he conducts to educate the general public on colorectal conditions and cancers.

Outside of medicine, Ramirez describes himself as “an easy-going family guy.” A father of five – including a son who plays professional baseball with the Oakland Athletics organization – he and his wife, Vicky, usually rise at 4 a.m. to work out in their home gym. He’s an expert there, too: a former competitive bodybuilder, he won a state lightweight championship in 1998. He also met Vicky in a gym.

Meanwhile, the family’s medical tradition may continue. Ramirez’s oldest son, Ray Jr., is a second-year student at EVMS and already has been in the operating room with his father.

“He is definitely drawn to surgery, and he could be our third-generation colorectal surgeon,” Ramirez says. “He’s seen how much I love what I do. I have the greatest job in the world.”

Eric C. Feliberti, MD

Surgical Oncology, Sentara Norfolk General Hospital and Sentara Princess Anne Hospital; Associate Professor, Department of Surgery, Eastern Virginia Medical School

 

As the child of a plastic surgeon, Eric Feliberti at first attempted to resist copying his father by going into medicine. The problem was that he always loved science classes, especially biology.

So he majored in biology in college and headed off to medical school, where he tried to at least resist becoming another surgeon. That didn’t work, either.

“Little by little, I just gravitated toward it,” he recalls. “I was drawn to the major operations, as well as to the challenge of helping cancer patients and their families. I found it was such fascinating and gratifying work, and I still feel that way today.”

As a general surgery oncologist, Feliberti treats all types of cancer, with colorectal cancer – along with breast cancer and melanoma – among the most common. He is attacking the disease from two sides: embracing minimally-invasive techniques but also introducing an aggressive two-part procedure called hyperthermic intraperitoneal chemotherapy, or HIPEC, to attack a deadly form of malignancy.

Effective new surgical techniques, particularly robotic surgery, have shortened recovery times and reduced side effects for many colorectal cancer patients. They also have allowed physicians to lower post-surgical pain medication, which can impede healing of the bowels and intestines. “Patients might only need two or three days in the hospital, compared to at least a week in the past,” Feliberti notes.

Patients with rare and complex tumors that have spread within the abdominal cavity, however, obviously need much more. In 2014, Feliberti became one of the first physicians in the region to offer HIPEC, which targets dangerous peritoneal surface malignancies shed by a variety of cancers, including colorectal adenocarcinoma. Fewer than 60 HIPEC programs exist in the United States.

The treatment begins with cytoreductive surgery to strip away all visible tumors within the abdomen. Surgeons then heat a liquid dose of chemotherapy drugs mixed in a sterile saline solution to more than 40 degrees Celsius – 104 degrees Fahrenheit – and pump it into the abdominal cavity, where it sits in place for 90 minutes.

“It essentially creates a bath that, hopefully, destroys any cancer cells remaining after surgery,” Feliberti says. “It’s designed to be a one-two punch, at maximum strength. We have found it can considerably increase life expectancy and reduce the rate of recurrence.” The only alternative for such patients would be traditional chemotherapy, which has very limited success, he adds.

The operation is grueling for patients, mainly due to its overall length and invasive nature, which makes local families even more grateful that they don’t have to travel to receive care. Yet because the chemotherapy portion targets only areas with cancer rather than diffusing into the bloodstream, there is minimum systematic toxicity and virtually no side effects. Other cancers that can cause peritoneal surface malignancies include appendiceal tumors, mesothelioma and primary peritoneal tumors.

Surgical oncology has proven to be a perfect fit for Feliberti, who enjoys getting to know patients and their families as well as teaching HIPEC and other advanced techniques to EVMS residents. He also has won multiple research grants, including three from Susan G. Komen for work on reducing breast cancer mortality among medically indigent women in Norfolk.

Born in New Orleans, Feliberti grew up in El Paso, Texas, as the youngest of four children; all of his older siblings became engineers. “I tell them that I’m an engineer of the body,” Feliberti jokes. After graduating from Cornell University, he completed his medical degree and a general surgery residency at the University of Texas Medical Branch in Galveston, followed by a surgical oncology residency at the City of Hope National Medical Center in California.

In 2006, Feliberti joined the EVMS faculty and is now Associate Director of Clinical Cancer Research at the school’s Leroy T. Canoles Jr. Cancer Research Center. He also holds multiple positions with Sentara, including Site Principal Investigator with Sentara Cancer Network’s Alliance for Clinical Trials in Oncology, and Co-Director of The Breast Center at Sentara Norfolk General Hospital. In addition, he is Chairman of the State Cancer Committee for the Virginia Chapter of the American College of Surgeons.

One current interest field is a national push to standardize treatment of rectal cancer. Sentara hospitals are collecting data for the Commission on Cancer’s National Accreditation Program for Rectal Cancer, or NAPRC, an effort to reduce variability in complication and recurrence rates and spare more patients from a permanent colostomy.  “This is about both survival and quality of life,” Feliberti says.

As a busy physician, Feliberti spends much of his free time with his wife and four children – three girls and one boy, ages 7 through 14. A longtime soccer player, he has mostly stopped playing due to bad knees but still coaches his kids’ teams.

So will one of his kids follow in his career footsteps one day? It’s too soon to tell, of course, although Feliberti notes that they aren’t too attracted by glimpses of procedure photographs. “Pretty much all they say is, ‘that is so gross, Dad,’” he relates with a laugh.

Then again, Feliberti also wasn’t going to be a doctor, either. And now he considers that decision one of the best he’s ever made.

Lisa A. Coleman DO, FACS, FASCRS

Colorectal Surgery, Tidewater Physicians Multispecialty Group, Mary Immaculate Hospital

 

One basic hurdle impacts Dr. Lisa Coleman’s work almost daily: too many patients don’t get to her quickly enough, whether they have advanced colon cancer or have struggled for years with benign anorectal conditions such as fecal incontinence.

So Coleman’s mission is to alleviate fears, dispel myths and educate local residents and health care providers about colorectal care, while offering the screening tools and advanced medical procedures that can save and change lives.

“There’s so much unnecessary shame and silence surrounding these health issues,” Coleman says. “I find great satisfaction in helping patients to feel comfortable and giving them renewed hope.”

Coleman chose to practice in Hampton Roads because the region is a known trouble spot for colon cancer death rates. According to a 2015 report published by the American Association for Cancer Research, southeastern Virginia ranked among the top three regions of concern – along with parts of the Mississippi Delta and Appalachia – with a rate 9 percent higher than the national average.

Coleman arrived at TPMG about a year ago, after 18 years of service as an Army Lieutenant Colonel who did wartime and humanitarian tours in Afghanistan and Honduras. Most recently, she spent six years as Chief of Colorectal Surgery and Endoscopy at William Beaumont Army Medical Center in Texas, followed by her last duty station at Ft. Belvoir in Northern Virginia.

Since colon cancer is often symptomless until its later stages, Coleman stresses that screening is critical for everyone, regardless of family history. She aims to partner with primary care physicians to recommend routine colonoscopies after age 50. “Early-stage colorectal cancers have a 90 percent cure rate,” she notes. “The screening also is far more tolerable than people think.” For patients who do have cancer or other damaged tissues, new minimally-invasive techniques and robotically-assisted surgeries can better preserve normal function and prevent permanent colostomy bags.

Coleman never shies away from uncomfortable topics. Take fecal incontinence, which often has a devastating impact on quality of life. Yet even as adult diaper sales soar, few patients discuss symptoms and not enough physicians bring up the topic at annual exams.

More common in women, fecal incontinence can arise for a multitude of reasons: old childbirth injuries, age-related muscle degeneration, neurologic conditions, side effects from medication or functional issues or blockages within the rectum and anus. “It requires a detailed evaluation by a specialist to determine the exact etiology and best course of action,” Coleman notes.

Treatment options include medication, surgery, muscle retraining, diet and lifestyle changes and a promising new therapy, sacral nerve stimulation. The latter utilizes an implanted neurostimulator, roughly the size of a cardiac pacemaker, which transmits mild electrical impulses to a lead wire placed near the sacral nerve plexus during a simple outpatient procedure.

“I had one woman come back to me with tears in her eyes, so thankful, telling me it was the first time in 30 years that she hadn’t soiled herself overnight,” Coleman says. “There’s nothing better than having the ability to improve someone’s life like that.”

A Chicago native, Coleman can’t remember a time she didn’t want to be a doctor. By age 16, she had joined a high school EMT service in Connecticut, where her family had moved, and didn’t blink at responding to car accidents and other traumas. She majored in biology at Mount Holyoke College in Massachusetts, with minors in chemistry, German and mathematics, and earned a medical degree at Western University of Health Sciences in California.

Coleman planned on becoming a trauma surgeon until she heard a guest lecture by a world-renowned colorectal surgeon, Dr. Stanley Goldberg, during her General Surgery residency at Tripler Army Medical Center in Hawaii. Goldberg described the rich variety of his work – from removing precancerous polyps during colonoscopies to performing complex abdominal surgeries and anal-rectal reconstructions – and also shared that only 9 percent of specialists were women.

“I remember thinking, ‘I’m sure there are women patients who would be more likely to address their problems with a female physician,” Coleman says. “This specialty had everything I wanted.” She went on to complete a fellowship in Colon and Rectal Surgery at St. Luke’s-Roosevelt Hospital in New York.

While on active duty, Coleman worked as a surgeon and instructor for medical residents at Army hospitals in Louisiana and Texas; in 2009, she deployed to Afghanistan for six months during Operation Enduring Freedom. She served as Chief Surgeon for a team at Forward Operating Base Lagman, earning a Bronze Star Award.

One of the biggest challenges was psychological, she relates: “As doctors, we’re not supposed to treat family members because it’s hard to think clearly with so much emotion involved. Well, these guys became my family. I ate breakfast with them every day and then saw them with these devastating injuries. As a mother – my two kids were very young then – it was painful when they’d say, ‘Tell my mom I love her.’ Since then, I have tried even harder to connect with my patients on a deeper level – to remember how scared they often are, even outside a war or trauma situation.”

In Hampton Roads, Coleman’s ultimate goal is to open a comprehensive multispecialty center for all pelvic floor disorders, many of which are interconnected. In the meantime, she welcomes calls not only from potential new patients but from physicians of all specialties.

“I will answer any question and give any advice I can,” she says. “The more everyone talks – the more that shame and silence stops – the better.”

Navigating the Complexities of the Colon

For colorectal surgeons, one question tends to come with the territory: Why would you ever choose this specialty?

The three physicians featured in this edition have many reasons, all of which fuel their drive to make a difference in the lives of their patients. Their field is high-tech, complex, challenging and constantly evolving. They also often have the satisfaction of curing people of life-threatening, debilitating and embarrassing conditions.

The colon is an intricate organ, with its coiled, densely muscular tubes that wind through much of the abdomen. Totaling roughly five feet in length, three inches in diameter and four pounds in weight in the average adult, it can develop a wide variety of problems, including cancer, ulcerative colitis, diverticulitis, fecal incontinence, rectal prolapse, severe constipation, anal fissures and hemorrhoids.

Such issues have plagued humans throughout history. In the Second Chronicles of the Bible, King Jehoram of Judah apparently suffered from severe rectal prolapse, or perhaps rectal cancer. As the King James edition reads, “The Lord smote him in his bowels with an incurable disease. And it came to pass, that in the process of time, after the end of two years, his bowels fell out by reason of his sickness: so he died of sore diseases.”

Ancient Egyptian papyrus papers mention anorectal diseases. Anoscopes were among the surgical instruments discovered in the ruins of Pompeii in Rome. All the way back in the 5th century BC, the Chinese recommended acupuncture as a treatment for hemorrhoids.

None of that is surprising, given that colorectal disorders are quite common – far more common than the patients who feel so isolated and self-conscious about them realize.

Hemorrhoids affect about 1 in 20 Americans, for instance, including about half of adults older than 50, according to the National Institutes of Health. Of the 1.6 million Americans with inflammatory bowel disease, roughly 900,000 have ulcerative colitis, which in turn increases their risk of colon cancer.

Colorectal cancer is the third most common non-skin cancer diagnosis in the United States, striking an estimated one in 21 people during their lifetimes. In cancers that affect both men and women, it is the second leading cause of death, trailing only lung cancer. Southeastern Virginia is a national trouble spot, too, with a colon cancer death rate 9 percent higher than the national average.

At the same time, many disorders are also highly treatable. Even colorectal cancer is both preventable and curable with regular screenings, prompt removal of precancerous polyps and early diagnosis of cancerous growths. The five-year survival rate for patients with stage I cancer is about 92 percent, according to the American Cancer Society; that drops to 11 percent for stage IV disease.

So Drs. Lisa A. Coleman, Eric C. Feliberti and Ray T. Ramirez are passionate about educating Hampton Roads residents and community physicians on the importance of colonoscopies, as well as about fighting the shame and silence that still surround colorectal disorders. Too often, they say, patients suffer for months, years or decades – and in some cases, forever – without asking for help.

Happily, patients who do speak up can benefit from multiple advances in the field, particularly laparoscopic procedures that reduce pain, recovery time and complications that require a permanent colostomy bag. Newer treatments even can extend to complex cancers, such as a combination of surgery and liquid chemotherapy used to attack tumors that have spread within the abdominal cavity.

As for all those “why” questions – and more than a few “rear-end” jokes – the colorectal surgeons profiled here aren’t offended by them. On the contrary, they tend to be a down-to-Earth bunch – skilled professionals who realize that a welcoming, occasionally light-hearted bedside manner helps patients more openly discuss problems that, if resolved, can no longer devastate their quality of life.

Theresa S. Emory, MD

Peninsula Pathology Associates
By Alison Johnson

 

After 13 years living and practicing pathology in rural southwestern Virginia, Dr. Theresa Emory is painfully aware of how many uninsured and underinsured women never schedule screenings for breast and cervical cancer. She has seen diseases caught far too late, such as one breast tumor that had pierced through the skin of a 36-year-old woman; the sample arrived with a small piece of her bra attached.

Now practicing with Peninsula Pathology Associates in Newport News, Dr. Emory is determined to help such underserved women through the See, Test & Treat program, a national outreach by the College of American Pathologists Foundation. A foundation board member, she led an effort to bring a day of free screenings to a hospital near the Virginia/Kentucky border this summer, and she hopes to do the same in Hampton Roads and the Eastern Shore within next two years.

“Simply put, these exams can save lives,” Dr. Emory says. “These women generally are very smart, but they tend to be so focused on their families – on taking care of other people – that they don’t take care of themselves. Many also have limited transportation options, major time constraints and a lack of funds. Our goal is to remove those barriers.”

Dr. Emory, who is affiliated with Riverside Health System, secured a $20,000 grant shortly after joining the foundation board in March 2016. She spent 17 months coordinating an event at Norton Community Hospital, about 420 miles from Newport News. On Aug. 5, she was among a multispecialty team of physicians and nurses who shepherded 44 women through 300-plus medical encounters, including mammograms, Pap tests, skin exams, bone density screens and routine blood work.

Most patients received same-day results, along with all needed referrals. The first woman through the door had critical hypertension and was sent to the emergency room; about 30 percent had abnormalities requiring follow-up care. Women also were counseled on nutrition, exercise, smoking cessation, diabetes care and local resources available to help them stay well.

“It was a really emotional day,” Dr. Emory says. “We had women who were so scared because they knew they’d put these tests off for too long, and then they were very relieved if they got good results. Everyone also was so thankful. There were a lot of hugs.”

See, Test & Treat has run for 10 years, but never before in Virginia and typically in urban areas or at large university hospitals. Many people were instrumental in organizing the Norton event, Dr. Emory stresses: two competing health systems partnered to host it; University of Virginia’s College at Wise opened dorms to volunteers; and Food City, a large supermarket chain, supplied breakfast and box lunches. Two other Hampton Roads physicians also participated: Dr. Lucy E. DeFanti of Peninsula Pathology Associates and Dr. Roger E. Emory – Dr. Emory’s husband – a plastic surgeon with offices in Williamsburg and Gloucester.

Much work remains to be done, Dr. Emory notes; according to the Centers for Disease Control and Prevention, just 38 percent of uninsured women receive mammograms, and 63 percent cervical screens, on a recommended basis. She already has an Aug. 4 date set for a second screening event in Norton, which she hopes can expand to 200 patients with additional radiology support.

Dr. Emory, a graduate of Eastern Virginia Medical School who is Board certified in anatomic and clinical pathology, has practiced locally since 2013. She encourages other community physicians to learn more about See, Test & Treat by contacting her or visiting foundation.cap.org.

“It should bother all of us that people in our own state are missing these screenings, ultimately presenting with advanced cancer,” she says. “My message to women is: by the time symptoms are bothering you, it will be much more complicated to treat. It’s not selfish to get screened. That’s how you can continue to be around for your family.”

 

Laurie A. Salerno, aNP-BC

Primary Care Provider & Cardiac Nurse Practitioner, JenCare Neighborhood Medical Centers

 

When Laurie Salerno started a Heart Failure Cardiology Clinic at her practice in 2015, she aimed high: she would take the sickest, most challenging, highest-cost patients and see if she could increase their healthy days and keep them out of the hospital.

The impact was virtually immediate.

Data on the first 44 patients in the six-week program, which covers understanding heart failure, medication, nutrition, exercise, symptom awareness and management of other chronic conditions, showed a dramatic drop in total hospital admissions. In the three months prior to being in the clinic, the group had 114 admissions, 60 of them for a cardiac diagnosis. In the six months following, those totals decreased to 14 and 3, respectively.

“We really can change the course of their disease,” Salerno says. “I love being on the front lines like that. I love having the time to develop close relationships with my patients. It’s easy to be passionate about my job.”

Along with her cardiac work, Salerno spends about 70 percent of her time as a PCP for JenCare, a group that focuses on seniors with a value-based model of care rather than fee-for-service. A native of upstate New York, she opted to become a nurse practitioner due to a long-standing desire to nurture others. In fact, she moved to Virginia in 2014 to care for her now-82-year-old father in her home.

Along with a nursing degree from D’Youville College in Buffalo, Salerno holds an Adult Nurse Practitioner master’s degree from State University of New York at Buffalo, where she did research on cardiac rehabilitation for heart failure patients. She has a wide medical background after 17 years as a registered nurse and another 17 as a nurse practitioner, most of them at Buffalo General Medical Center. There, she helped create an outpatient center for heart and lung patients that included a training component for medical students and residents. Concurrently, she was in a private internal medicine and cardiology practice for 12 years.

At JenCare, Salerno recently completed a successful pilot exercise program for heart failure patients, incorporating strength, endurance and balance training. Her next goal is to develop a dietary program for all patients, not only those with heart issues. That would emphasize a whole-food, plant-based diet, along with some lean poultry and fish, while limiting fat, salt, sugar, red meat and dairy.

“We could make so many improvements simply through food, from managing diabetes and blood pressure to reducing arthritis inflammation and the risk of certain cancers,” she says. “We need to be practical, too: If I’m on a limited budget at Wal-Mart, here’s what I should buy. If I’m on a low-sodium diet at Subway, I can order the tuna or roasted chicken.’” (Salerno also revamped JenCare’s snacks, kicking out salty pretzels and Chex Mix while keeping fruit, low-salt snacks and sugar-free cookies.).

Not surprisingly, Salerno is a giver outside work as well. Along with caring for her dad, she is guiding her 56-year-old husband through early-onset Alzheimer’s disease and has two grown daughters adopted out of foster care. “They were 9 and 12 when I met them, and their first question was, ‘Please, are you going to adopt us?’” she recalls. “They’d spent almost 10 years bouncing from family to family.” Salerno also has two stepchildren, five grandchildren and six rescue animals, four cats and two dogs.

In addition, church volunteer work has taken Salerno to Haiti five times; she also traveled on a 2017 medical mission to Nicaragua through JenCare.

About to turn 60, Salerno has no plans to slow down anytime soon. “My work gives me so much energy,” she says. “I feel blessed that I’m in a position to give my senior patients the kind of care that they deserve.”

Advances in Imaging Devices Set the Pace for Cardiac Care

New technologies, from the heart-lung bypass machine in the 1950s to the miniaturized echocardiogram transducers of today, has changed the delivery of cardiac care. These advances in imaging tools and technologies, as well as in the size and capabilities of catheters, are improving cardiac treatment options and quality of life for patients in Hampton Roads and across the globe.

 

Percutaneous Treatment of Valvular Heart Disease
Thousands of patients have now benefited from rapidly developing percutaneous treatments for valvular heart disease. These treatments are made possible by the development of specially designed stents that expand and contain an artificial valve.

Dr. David Adler

“Recent developments in structural intervention are exciting, namely the transcatheter valvular therapies for valvular heart disease,” says Dr. David Adler, an interventional cardiologist who practices at Cardiovascular Associates, a Bayview Physicians Group practice, and is on staff at Sentara and Chesapeake Regional Healthcare.

“In my world, these advances are exciting and welcomed,” Dr. Adler says.

Percutaneous approaches primarily benefit older, high-risk patients with multiple co-morbidities. As Baby Boomers age, this patient population is expected to increase and raise the demand for catheter-based approaches.

Many of these novel therapies are already seeing success, lowering the rates of morbidity and mortality in high-risk patients. Current effective treatments include:

• Transcatheter aortic valve replacement (TAVR) for aortic stenosis

• Transcatheter pulmonary valve replacement for pulmonary stenosis

• Transcatheter mitral valve repair for degenerative mitral regurgitation

“To date, [transcatheter aortic valve replacement] is very impressive for those who are at a high risk for open heart surgery. This has shown to be a better option. It has moderate risk and the benefit is that the patient has an easier recovery. Most can leave the hospital in 24 to 48 hours after it is done,” Dr. Adler says.

Percutaneous approaches for valvular heart disease still need further study and refinement. Research is underway to develop transcatheter mitral valve replacements as well as improve the efficacy of existing valve replacements. As these procedures improve, physicians are likely to utilize them more and more often while serving a wider range of patient populations.

 

Catheter Ablation for Abnormal Heart Rhythms
Dr. Edward Chu, interventional cardiologist with Riverside Cardiology Specialists, says there have been great advances in the treatment of abnormal heart rhythms in the form of catheter ablation.

Dr. Edward Chu

Cardiac electrophysiologists utilize catheter ablation to treat a variety of arrhythmias, from atrial fibrillation to ventricular tachycardia. While radiofrequency catheter ablation is still the most commonly used procedure, current research is examining the benefits and efficacy of cryotherapy and laser energy ablations. Some electrophysiologists consider cryotherapy to be a safer approach; however, studies have shown that patients are more likely to experience recurrence of arrhythmias after cryoablation than radiofrequency ablation.

New devices and imaging approaches are improving the effectiveness and safety of ablation procedures. Advanced catheters can offer vital information about contact force between the catheter and heart tissues, helping physicians use the right force to create appropriate lesions without risk of perforation. Multi-array ablation catheters allow physicians to create lesions in multiple parts of the heart at once. However, these catheters have mixed success and need further study.

Electrophysiologists are also finding intracardiac echocardiography (ICE) provides more accurate guidance of ablation procedures. The catheter-tipped miniaturized echo transducer offers real-time images of the heart as well as evaluation of tissues. The use of this device may lead to a reduced risk of damage to healthy tissues as well as improve precision of lesions. ICE is not currently used widely for ablation procedures, but may become more common as catheter ablation procedures become more targeted.

 

Radial artery catheterization
Radial artery catheterization for interventional procedures became possible in the early 1990s thanks to new, more delicate catheters that could move through the smaller arteries in the wrist. This approach continues to grow in popularity for both diagnostic and interventional procedures. The procedure is becoming safer as physicians gain more experience with this delicate approach to catheterization.

Dr. Chu states that at Riverside Regional Medical Center, catheterization is now commonly accessed by the radial artery. The procedure is more comfortable and the patient is released from the hospital sooner than with the femoral access site. Patients are also at a lower risk for bleeding with the same high success rates achieved with femoral artery catheterization.

 

Dr. Jonathan Fleenor

Treatment for the Smallest Heart Patients
Children’s Hospital of The King’s Daughters (CHKD) has the only accredited fetal echocardiography lab in the region. Fetal echocardiography uses ultrasound technology to create a more detailed picture of the fetus’s heart than is obtained from a standard ultrasound, says Dr. Jonathan Fleenor, director of cardiology at CHKD.

Fetal echocardiography shows the fetus’s heart structure, blood flow and heart rhythm, allowing the accurate diagnosis of many, but not all, heart problems.

A special prenatal team consisting of a pediatric cardiologist, pediatric sonographers and a social worker works closely with the families. They also work with referring physicians, neonatologists, geneticists and others as needed to create prenatal and postnatal management plans, Dr. Fleenor says.

Many of the mothers who undergo fetal echocardiography are patients of the Maternal Fetal Medicine Department at Eastern Virginia Medical School, the region’s referral center for high-risk pregnancies.

Most mothers usually deliver their baby at Sentara Norfolk General Hospital, which operates a perinatal intensive care unit for high-risk patients and complicated births.

CHKD’s neonatal unit is connected to Sentara Norfolk General by an interior hallway, allowing neonatologists to easily attend births and begin care in the delivery room.

 

Collaboration between CHKD and University of Virginia
Hampton Roads children with heart conditions will receive the most up-to-date treatment with the recent collaboration between CHKD and University of Virginia Children’s Hospital in Charlottesville.

The partnership between the two cardiac programs, led by Dr. Jay Gangemi, combines the medical efforts of pediatric cardiologists, cardiac surgeons, cardiac anesthesiologists, intensive care physicians and cardiac support professionals.

The University of Virginia’s pediatric cardiac surgery program is ranked among the best in the nation according to, U.S. News and World Report, while CHKD has the highest volume pediatric surgical program in the Commonwealth, according to Jim Dahling, president and CEO of CHKD Health System.

Dr. Fleenor says that prenatal diagnosis of babies with heart conditions through technology like fetal echocardiography is a major benefit to successful treatment. If a fetus is found to have a heart condition, physicians can immediately begin preparations for proper medical intervention.

“Together with UVA, we can come up with the best plan. In cases like this, it is always good to have an extra set of eyes,” Dr. Fleenor says.

Heart problems occur in 1 percent of babies born in the area, and about a quarter of these problems are critical. While the percentage may seem low, Dr. Fleenor says it is the most common birth defect overall. Physicians perform about 150 heart surgeries each year at CHKD.

As imaging becomes clearer, catheters become smaller and devices become more effective, cardiac patients of all ages will have the treatment options they need for a higher quality of life.

Lipid Management and Continuity of Care

By Linda G. P. Schneider, MD

I have a distinct memory from medical school –around the time when studies began to emerge linking high cholesterol to heart disease– of my professor lecturing passionately in defense of the “natural hardening of arteries”.  In this era of medicine, the widely held view was that the excess buildup of plaque in arteries, or atherosclerosis as we know it today, was a natural part of the aging process.

We now, of course, know high cholesterol to be a contributing factor in the risk for heart disease and have a better understanding of the steps that can be taken to manage, and lower, a patient’s dangerously high levels.

For a patient newly diagnosed with high cholesterol, or for one who has been working with a physician to manage their levels, there is often a lingering, ever-present fear of a potential heart attack or stroke in the distant, or not so distant, future.

This fear can be exacerbated for a patient with a predisposition to high cholesterol or whose risk factors are increased due to a genetic component or condition.

In these cases, a Lipid Specialist can step in with the knowledge and added expertise to serve as an additional resource for patients and physicians navigating the often-frustrating journey towards a personalized and successful treatment plan. Added emphasis is placed on early intervention before a high cholesterol diagnosis – more specifically before a life-threatening, and often life-changing, adverse cardiac event or stroke.

In such cases as Familial Hypercholesterolemia, through early intervention with the patient and their families a genetic link can be established; this empowers patients to take control of their health before cholesterol levels become dangerously high, increasing their risk of a heart attack or stroke.

With heart disease as a leading cause of death in men and women, the importance placed on collaboration between a Lipid Specialist, primary care physician and the patient in high cholesterol management and treatment can lead to modified outcomes.

Consultations for Lipid Specialists often range from a single visit to review medications to multiple visits until we find a successful management regimen.  In the majority of cases, once a patient’s cholesterol levels are manageable, the patient returns to the care of their primary care physician.

When it comes to patient care, a Lipid Specialist should be viewed as any other specialist – a member of the patient’s physician team devoted to continuity of care and collaborating to find the best treatment plan, while assuaging a patient’s fears and working towards better outcomes.

Linda G. P. Schneider, MD is a family medicine physician and lipid specialist with TPMG Hampton Family Medicine. She is Board certified in Family Medicine and a Diplomate of the American Board of Clinical Lipidology.  www.mytpmg.com

Dizziness & Balance Disorders

By Susan Smigielski Acker

The room spins. It can happen to anyone, but when a patient says it occurs regularly, it is time to consider what is causing it.

Dr. Patricia Mayes

Nearly 5 percent of patients presenting to the neurology clinic complain about being dizzy, according to Dr. Patricia Mayes, a neurologist at Tidewater Physicians Multispecialty Group (TPMG) Neurology in Williamsburg.

While the percentage may seem low, in 2011, 2.5 million patients complained about it. And the cost to treat balance disorders and dizziness is more than $1 billion per year, says Dr. Barry Strasnick, Professor and Chairman of the Department of Otolaryngology/ Head and Neck Surgery at Eastern Virginia Medical School.

The chances of a patient complaining about feeling dizzy and having trouble with balance increases tremendously as they age. It is simply more common in elderly patients, Dr. Mayes says.

“About 75 percent of those over the age of 70 will experience some sort of balance disorder. But I see all ages in my office,” Dr. Mayes says.

In addition to feeling dizzy, patients often complain of being lightheaded, experiencing blurred vision, falling and feeling confused, Dr. Strasnick says.

So Many Reasons
The challenge is figuring what is causing it because according to Dr. Mayes, “there are so many causes for the same problem.”

The differential diagnoses include conditions that affect the inner ear or the central nervous system, according to Dr. Mayes.

Dr. Barry Strasnick

Dr. Strasnick agrees and gives examples including hypertension, diabetes, epilepsy, head trauma, tumors, infections, encephalitis, multiple sclerosis, migraines and autoimmune disorders.

Patients can experience vertigo with or without hearing loss, Dr. Mayes says.

Medications such as antibiotics, sedatives and tranquilizers can be to blame as well, Dr. Strasnick adds.

While uncommon, dizziness may be a manifestation of a stroke or similar circulation problem. Dizziness is not a typical symptom of a stroke, so many people do not seek medical treatment right away, Dr. Mayes says.

“The best way to rule out a stroke or even a tumor is with an MRI of the brain,” Dr. Mayes says.

What To Ask 
When a patient complains about feeling dizzy or having trouble with their balance, Dr. Mayes says physicians need to ask the following questions

When did it start?

How long does an episode last?

Is it intermittent or constant?

Dr. Strasnick says that asking the patient to describe the sensation can also be helpful. Does the room spin or is it more of a lightheaded or imbalanced sensation?  Another key is to ask about symptoms often associated with dizziness, including tinnitus, hearing loss and other neurologic symptoms.

So Many Causes
The majority of cases of dizziness are caused by problems affecting the inner ear.

An inner ear disorder known as Benign Paroxysmal Positional Vertigo, (BPPV) is the most common cause of vertigo accounting for up to 25 percent of all cases. It is characterized by acute attacks of vertigo lasting seconds to minutes. It is typically aggravated by head position change and accompanied by visible involuntary movement of the eyes. This disorder is due to displacement of tiny calcium crystals within the inner ear, leading to vertigo that occurs with position changes.

For this condition, Mayes says a simple in office treatment known as the Canalith Repositioning Maneuver (often referred to as the Epley Maneuver) is recommended. This procedure repositions the displaced particles within the inner ear into their proper location, thereby resolving the dizziness.  This non-invasive procedure is commonly performed by properly trained physicians or physical therapists. Typically this treatment results in a more than 90 percent success rate in terms of complete resolution of the positional dizziness. For those rare instances of BBPV that arerefractory to repositioning maneuvers, surgical treatment is available.

In many cases dizziness can be due to a virus affecting the inner ear or balance nerve. In these instances, Strasnick says corticosteroids and/or a specific balance therapy known as vestibular rehabilitation therapy is recommended.

Meniere’s Disease, an inner ear, disorder which involves a problem with fluid regulation within the inner ear affects up to 2.5 million individuals. In these cases it is important that patients restrict their salt and caffeine intake. Diuretic therapy is typically administered to further reduce fluid accumulation within the inner ear. Additional options include vasodilator medications and injection of steroids into the middle and inner ear, Dr. Mayes says.

Strasnick adds that surgery is an option for patients with Meniere’s Disease who do not respond to medical therapy.

Migraine sufferers commonly experience dizziness, motion intolerance, loss of balance and even true vertigo. Treatment typically is directed towards preventing the occurrence of the migraine process with a variety of medications.

Patients who suffer from multiple sclerosis have a 50 percent chance of experiencing vertigo. In fact in up to 15 percent of cases vertigo can be the initial presenting symptom. Treatment generally includes medication to reduce the vestibular response, Dr. Strasnick says.

Patients sustaining head trauma commonly experience dizziness and balance problems, which in some instances can be prolonged and very resistant to therapy, Strasnick explains.

To treat vestibular dysfunction, it is important to understand that immobilization actually reduces vestibular compensation while repetitive activity enhances compensation. The optimal strategy, then, is to provide short-term relief while at the same time preserving the underlying sensory conflicts to allow for longer term compensation, Dr. Strasnick says.

Dr Strasnick notes that there are a number of pharmacologic options to treat dizziness, including anticholinergics, antihistamines and benzodiazepines. Similarly, surgical treatment is available for many instances where medications fail to provide relief.

The management of a dizzy patient also often includes vestibular rehabilitation therapy. This modality of treatment takes into consideration that the vestibular system has the ability to adapt and compensate, provided the non-vestibular sensory inputs such as vision and proprioception remain intact. Individual exercises that rehabilitate pathologic vestibular responses are provided through vestibular rehabilitation therapy, and these exercises can be performed by the patient in the comfort of their own home, according to Dr. Strasnick.

Documentation is Key in Legal Protection

By Jessica Flage, Attorney at Law

The Medical Update article about balance disorders and dizziness states that 75 percent of people over the age of 70 have some sort of balance disorder which can cause dizziness, thereby making them prone to falls.

It is no secret that when an elderly person falls it can hasten their decline and be fatal.

The doctors interviewed for the article agree there are many potential causes for balance problems – everything from head trauma to inner ear disorders.

As an attorney who defends physicians in malpractice claims, a common mistake that these clients make when evaluating and treating a patient with balance disorders and dizziness (or any patient) is limited documentation. Just like in old school math class, it is important to show your work.

The reason? In a situation where medical negligence is alleged by the patient or their relatives, the defense of these cases often hinges on the documentary evidence. Simply put, documentation can be evidence.  It can show what you were thinking, what you were not thinking, what you ruled out, how you ruled it out, and why. Plaintiffs use documentation to prove that good care was not provided. Defendants use it to prove good care was provided and how.

Many cases are not brought to trial until years later, so proper documentation can also refresh your memory.

A heavy patient load and electronic medical records can make good documentation challenging. Check the boxes that apply and make notations where you can. Taking time to make notations protects you and your practice.

While working through the causes of complicated conditions such as dizziness and balance disorders think about who might see your records later. Countless lawsuits happen when it’s difficult to understand the physician’s thought process.

All procedures and tests performed need to be listed on the patient’s chart.  If you decided not to do a procedure or test, document that as well. When causes are ruled out, document your reasons for the conclusion.

When recording, include your assessments, identification of other health issues, plan of care, implementation, and evaluation. Medication risks should be discussed with the patient and that discussion should be noted. The patient’s decline should be recorded. If a specialist or expert is consulted, include his or her findings and recommendations.

Record the time of the visit, making sure date and time are stamped.  If you are unable to record during the visit, include the date and time you are recording and the visit.

Strong record keeping is crucial in dealing with abusive or non-compliant patients. It’s also important with patients with a complaint who do not show improvement.

Whether the patient is in the hospital, at home, or in a nursing facility, it is critical that all tests and care be documented by the physician, any midlevel providers, nurses, and staff.

Elderly patients may not understand who’s allowed access to their information. With HIPAA laws, only authorized family can learn about a patient’s medical condition and recommendations. It may be beneficial to discuss with elderly patients their desire to bring family into the fold. Start by asking: as things develop, who can we communicate with?

Lastly, take time to keep authorized family members involved.  They may seem content in your office, but that can change quickly with an adverse event.

Jessica Flage earned her law degree in 2007 at American University Washington College of Law. She focuses her practice primarily in the areas of medical malpractice defense litigation, healthcare and product liability defense with Goodman Allen Donnelly.  www.goodmanallen.com