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eRounds - Winter, 2013


Success with Shared Appointments

Shared medical appointments have been a surprise success with patients and referring physicians. They are now being offered in a number of specialties at Cleveland Clinic. You may want to consider referring your patients for this kind of appointment when you think it would be appropriate.

The physician-patient bond is sacred. But it doesn’t have to be isolated. Shared medical appointments (SMAs) offer an innovative, interactive approach to healthcare that brings patients with common needs together with one or more healthcare providers. While an individual appointment typically lasts 15 to 30 minutes, a shared appointment is 90 minutes long, allowing participants to spend more time with the healthcare team.

Cleveland Clinic piloted SMAs more than 10 years ago and now offers them at several Cleveland Clinic hospitals and family health centers. During a typical SMA, 10 to 15 patients are seen together in a setting that encourages asking questions and sharing concerns and experiences. Patients learn from the healthcare team and from each other in this environment.

Patients have been overwhelmingly satisfied with the program. They enjoy the opportunity to relate to other people who are dealing with similar health issues, share stories and ideas, learn from one another, and truly create a bond. SMAs are particularly valuable to people dealing with chronic conditions such as asthma, diabetes and hypertension.

Every patient has the opportunity to be a role model to someone else. For example, a 60-year-old asthma patient got back on the treadmill after being motivated by a 10-year-old who was successfully managing his asthma out on the basketball court every day.

During the shared visits, patients can also be seen in a private exam room for individualized care, as needed.

Shared medical appointments aren’t always appropriate. They are not intended to completely replace individual office visits and aren’t recommended for initial evaluations, one-time consultations, treatment for urgent medical concerns, or complex care.

Group visits are especially beneficial for patients who need routine follow-up for chronic conditions, those seeking more information regarding their specific health issues, and those who require mind and body care; these are typically patients who require additional time with their physician.

Learn the essentials and benefits of shared medical appointments in your practice as we share our experience and the impact on the patient experience and quality of care. Marianne Sumego, MD, Director of Shared Medical Appointments at Cleveland Clinic, is offering a CME course on “Changing Healthcare: One Shared Medical Appointment at a Time” on April 25-26, 2013. To learn more, visit ccfcme.org/sma.


Wrist Work

Improvements in carpal bone fusion may help your patients with degenerative wrist arthritis.

High-tech hardware can preserve range of motion and reduce pain.

Wrist arthritis punishes those who have it. They can’t grip. Often they lose motion in addition to their grip.

What causes arthritis of the wrist or carpal bones? Usually it’s an old sprain causing the carpal bones to shift over time and the joint to wear out or a result of a fracture that extends to the surface of the joint. Of course, rheumatoid arthritis, gout and other inflammatory conditions can affect the wrist as well as other joints.

Splints, medication and lifestyle changes are the first line of treatment. Severe cases may be treated surgically.

Treatments include bone fusion, removal of diseased wrist bones or total wrist replacement. Total fusion successfully reduces symptoms but sacrifices range of motion; partial fusion maintains up to half of wrist motion. Removal of the first row of wrist bones can preserve more motion but is not an option for advanced disease.

The goal of partial (limited) arthrodesis is to create a stable, painless unit linking the proximal and distal carpal row and removing the diseased portion. Some of the carpal bones, like the triquetrum, may be removed to improve motion. Lunate position within the fusion is critical.

The hardware involved in partial carpal fusions has evolved significantly over the years. Traditionally, it was done with K-wire fixation that only holds the bones still and requires a second procedure to remove them. More recently, compression screws and circular fixation plates have increased the rate of union and eliminated the need for hardware removal. The results have been mixed and difficult to evaluate because the metal parts are radiographically opaque.

Cleveland Clinic has been using a new variable-angle, circular locking plate that overcomes some of the deficits of earlier circular plates. It is made of polyether ether ketone, a radiolucent polymer with a bonelike elasticity. It has been used in both the wrist and the foot. Its titanium screws allow for bony compression and also lock into the plate at variable angles, enabling multiple screws to be placed into each bone.

The instrumentation includes a reamer that allows for full recession of the plate into the carpal fusion mass to avoid any dorsal impingement on the radius.

Cleveland Clinic has been using this plate (known as Xpode®) for more than two years in limited carpal fusions. The preferred technique is to resect both the scaphoid and the triquetrum and perform a three-bone fusion with at least two screws each in the capitate, lunate and hamate.

Cleveland Clinic continues to investigate Xpode, but early results in 21 patients after seven months demonstrate only one nonunion (an issue with previous techniques). There has been good range of motion and reduction in pain. Complications have been minimal.

These early results are encouraging. It appears that the combination of technical modifications to the original four-corner fusion technique and new implants may benefit patients with degenerative wrist arthritis.

To refer a patient to one of our upper extremity surgeons, please call 855.REFER.123 (855.733.3712).


IVC Filter Retrieval Clinic: Ensures Quality and Safety

A new inferior vena cava (IVC) filter can help prevent pulmonary embolism from deep-vein thrombosis — but can cause a new set of problems if it is not removed in a timely fashion.

As the population ages, the incidence of deep-vein thrombosis (DVT) leading to pulmonary embolism (PE) increases. The U.S. Surgeon General has estimated that DVT and PE affect as many as 600,000 people and contribute to 100,000 deaths annually.

Most of these patients are at increased risk of these conditions because of surgery, trauma, immobilization due to medical issues, pregnancy, or previous history and can be successfully managed with anti-coagulant drugs. A subset of this group cannot receive or do not respond to medical anticoagulation efforts. An increasing number of these patients are now being treated with inferior vena cava (IVC) filters — devices that fit in the IVC to capture emboli before they can reach the pulmonary arteries.

There are several different types of vena cava filters. They are generally wire structures made of stainless steel or nickel-titanium alloy (nitinol). They are placed percutaneously via the groin or neck, at a site just below the renal junction in the IVC. Some IVC filters are intended to be permanent. Others, however, are meant to provide only temporary protection and are designed for potential percutaneous removal once protection against PE is no longer needed. Unfortunately, many patients are not receiving the appropriate follow-up to ensure that removal occurs as soon as it is advisable to do so. As a result, the FDA has received more than 900 reports of adverse events with IVC filters including device migration, embolization and filter fracture. In very rare cases, IVC filters have migrated to chambers of the heart.

Cleveland Clinic is addressing this problem. An IVC Filter Retrieval Clinic has been established in the Sydell and Arnold Miller Family Heart & Vascular Institute under the leadership of John R. Bartholomew, MD, Section Head of Vascular Medicine and Mark Sands, MD, Section Head of Interventional Radiology. Shelly Brancatelli, RRA/RPA, RT, coordinates the team effort.

Drs. Bartholomew and Sands are Medical Directors of Cleveland Clinic’s Quality and Patient Safety Institute. “This is a quality and safety initiative,” says Dr. Bartholomew. “The FDA and the Society for Interventional Radiology recommend that IVC filters be removed as indicated.”

The IVC Filter Retrieval Clinic welcomes patients at all stages of treatment with IVC filters. This includes patients who are having or have recently had an IVC filter placed and need to be managed by a vascular medicine specialist in conjunction with an interventionalist who can determine when the filter can be removed. It also includes patients who have had a temporary IVC filter placed and never had it removed.

“We will work with the individual patient to determine when removal is safe and advisable,” says Dr. Bartholomew.

Most IVC filters can ultimately be removed when they are clinically no longer necessary. In some cases, the removal of IVC filters can present technical challenges. Cleveland Clinic has the experience and technical expertise to successfully address any contingency in IVC removal.

“It is always recommended that temporary IVC filters be removed at a high-volume center,” says Dr. Bartholomew, “by professionals who are familiar with the full range of devices and any possible complications.”

The IVC Filter Retrieval Clinic encourages inquiries from any physician who would like to refer a patient. “We look forward to collaborating with you in providing the best management for your patients with IVC filters,” says Dr. Bartholomew.

For more information about the IVC Filter Retrieval Clinic, contact Dr. Bartholomew at 261.444.0825 or barthoj@ccf.org.


Personalized Genetic Healthcare Goes Deep

Your patients may be at risk for diseases that run in their families or lie hidden in their genes. The Cleveland Clinic Center for Personalized Genetic Healthcare has the time, technology and specialized knowledge to thoroughly analyze your patients’ genetic risk – and help make your personalized care even more personal.

“The mapping of the human genome and the ongoing discovery of epigenetic influences have given us new tools to understand and prevent common and deadly diseases,” says Rocio Moran, MD, a clinical geneticist in the Cleveland Clinic Center for Personalized Genetic Healthcare. “We partner with primary care physicians to identify patients who are at risk for inherited disorders. We are able to provide the kind of intensive screening that can reduce a patient’s risk of contracting the disease or dying of it.”

A primary care physician who suspects a patient could have an inherited condition may not have the time to provide comprehensive risk assessment and genetic counseling. The Center for Personalized Genetic Healthcare can devote as much time as a patient needs for risk assessment and counseling and can offer the referring physician a full report on its findings.

Genetic counselors can help patients identify the most appropriate genetic test for their concerns. They can help patients understand the difference between widely available commercial gene tests and high-penetrance genetic testing that may have actual utility.

“The fact is that family history is a powerful tool for genetic screening,” says Dr. Moran. “If there is an indication of inherited disease, we’ll take 20 minutes to half an hour to do an in depth family history and tease out the meaningful elements. We explain to the family why this is important and answer their questions. We let them know what can and can’t be done.”

“Because of the complexity of genetics and genomics, we need to be available to explain a patient’s test results,” says she continues. “We will spend an hour or two with the patient and family members to discuss the full implications of what we’ve learned and what it could mean for them.”

The Center for Personalized Genetic Healthcare is there for patients when the diagnosis is inherited Alzheimer disease or other difficult conditions. “It can be a very heart-wrenching education,” says Dr. Moran. “A diagnosis can change family dynamics. We’re sensitive to this. When we are testing for some disorders, we ask the family in advance how they would like us to deliver the news. We give them resources for additional information and suggest ways of informing other family members.”

Same-day appointments are available in the Center for Personalized Genetic Healthcare. When Dr. Moran and her colleagues order genetic testing, the results are returned in two to eight weeks. The team works closely with in house and external testing labs to make the right recommendations.

“We do comprehensive assessments that are not just in one organ system but take a broad sweep of the patient,” says Dr. Moran. “We bring the puzzle pieces together to provide clarity for the patient and referring physician.” Marfan syndrome, for instance, can involve the heart, vascular system, bones and eyes. As part of Cleveland Clinic’s multispecialty group practice, patients referred to the Center for Personalized Genetic Healthcare have access to the full range of diagnosis and treatments.

“Any good physician is already doing what might be called personalized healthcare,” says Dr. Moran. “Our center is another tool in the toolbox. We give the physician access to our special expertise and all the necessary follow-up.”

Dr. Moran sees the Center for Personalized Genetic Healthcare as an indicator that we are moving toward an era of proactive rather than reactive medicine. “We are just beginning to understand the complexity of genes and epigenetics and how they play into the risk for diseases,” says Dr. Moran. “In time, this understanding will help drive medicine in a cost-effective direction. I do think it will continue to inform and direct healthcare in a positive way.”

To schedule a genetic evaluation for your patient, please call 216.636.1768 or 800.998.4785. Or fax relevant records to 216.445.6935.

The Center for Personalized Genetic Healthcare — part of Cleveland Clinic’s Genomic Medicine Institute — is a national leader in genetic health. We employ one of the largest teams of genetics experts, who provide counseling and testing services in the areas of:

  • General genetics
  • Cancer genetics
  • Cardiovascular genetics
  • Neurogenetics and the genetics of neurometabolic disorders
  • Pediatric genetics
  • Prenatal and preconception genetics

Chronic Wounds Get Hyperbaric Treatments

Most chronic wound issues involve diabetic ulcers, pressure ulcers and slow-healing wounds. You may be seeing more of these cases as rates of diabetes mellitus increase. Cleveland Clinic is available to assist your treatment of these patients. Our specialized Wound Healing Centers offer a multidisciplinary approach to diabetic ulcers, pressure ulcers, infections, and compromised skin grafts and flaps.

Cleveland Clinic Wound Healing Centers are able to assess wounds from the topical to the cellular level and offer the most appropriate treatments at each stage of care. Specialists offer the highest level of traditional treatments, along with hyperbaric oxygen therapy (HBOT).

HBOT has been used for decades to treat decompression sickness, gas embolism and carbon monoxide poisoning. It has also proven useful in treating infection resulting from anaerobic bacteria and other difficult to-resolve wound problems. HBOT increases the amount of oxygen in the patient’s bloodstream, allowing oxygen to pass more easily through the plasma into the wounds and heal them.

Specially made hyperbaric oxygen chambers surround patients with 100 percent oxygen at higher-than normal atmospheric pressure. The walls of the chambers are transparent. Patients lie on a bed and can listen to music or watch movies while receiving treatments.

Many severe wounds have tissue that is insufficiently oxygenated or hypoxic. This can result in gangrene or other dangerous conditions. HBOT temporarily reoxygenates tissue and over the course of multiple treatments accelerates wound-healing processes — including (in some cases) neovascularization. Cleveland Clinic Wound Healing Centers use HBOT to treat diabetic wounds and wounds that have not shown improvements in four weeks. They also use HBOT to treat certain bone and skin infections, radiation injuries, compromised skin grafts or flaps, gangrene, and carbon monoxide poisoning, as well as:

  • Actinomycosis
  • Acute traumatic peripheral ischemia
  • Acute peripheral arterial insufficiency
  • Chronic refractory osteomyelitis
  • Crush injury/compartment syndrome
  • Diabetic wounds of the lower extremities
  • Gas gangrene
  • Osteoradionecrosis
  • Preservation of failing graft or flap
  • Progressive necrotizing infections
  • Soft tissue radiation injury

There are Wound Treatment Centers at Lutheran and South Pointe hospitals.

To make a referral to the Wound Healing Center at South Pointe Hospital, call 216.491.7111. To make a referral to Lutheran Hospital’s Wound Healing Center, please call 866.566.9670.

Lower Extremity Wound Clinic

Cleveland Clinic’s Heart & Vascular Institute treats wounds and ulcers of the legs and feet at its main campus and Independence Family Health Center. The Lower Extremity Wound Clinic treats wounds consequent to venous insufficiency, lymphedema, diabetes, pressure, cancer, inflammatory disease and other medical problems. Specialists in vascular medicine, vascular surgery, infectious disease, plastic surgery, podiatry, dermatology, and orthopaedics offer state of the art technologies for diagnosis and treatment as well as topical wound care therapies, compression garments, and prosthetics or orthotics. The goal is to prevent the need for amputation.

The Cleveland Plain Dealer recently wrote, “CHEERS … to the staff of the Lower Extremity Wound Clinic at the Cleveland Clinic, who work to keep people from losing limbs — and even their lives — to complications from diabetes.”

To make a referral to the Lower Extremity Wound Clinic, please call 216.444.4420.

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