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eRounds - Winter 2012


New Cardio-Oncology Center Created

Cleveland Clinic’s Heart & Vascular Institute (HVI) and Taussig Cancer Institute (TCI) have created a new Cardio-Oncology Center focused on preventing or minimizing heart damage caused by chemotherapy and radiation. The new center is co-directed by HVI’s Juan Carlos Plana, MD, and TCI's Thomas Budd, MD.

“There is always a chance that some cancer treatments can increase the risk of heart failure or cause the heart to weaken,” says Thomas Marwick, MD, head of the Section of Cardiac Imaging. “We have sophisticated imaging technology to help us identify patients whose hearts may not be happy with cancer medication so we can take measures to prevent heart failure.”

The imaging technology utilized is called “strain imaging” and it allows physicians to get a detailed analysis of specific segments of the heart in order to predict damage before it occurs. In a promising, small-scale study, strain predicted issues up to three months earlier than monitoring ejection fraction alone.

Not all patients undergoing cancer treatment experience heart damage. Those who should be considered for a consultation in the Cardio-Oncology Center include patients who have either already undergone chemotherapy and/or radiation therapy in the past and are presenting with symptoms of heart disease (such as weakness or fatigue, shortness of breath, swelling of the feet and legs, chest pains and irregular heart rhythm); or those who are newly diagnosed with cancer and also have, or are at risk for developing, heart disease. For these patients, the Cardio-Oncology Center team will develop an individualized strategy to minimize cardiotoxicity.

To learn more about the Cardio-Oncology Center, you can contact Dr. Plana at 216.444.5910 or planaj@ccf.org.


Home Sperm Banking Service Now Available

All of Cleveland Clinic’s endeavors focus on putting the patient first. In keeping with this long-established tradition, the Andrology Laboratory recognizes that many patients may view sperm donation as a personal and private activity.

The Andrology Lab and Reproductive Tissue Bank has established the new and novel NextGen (SM) Home Sperm Banking Service. Individuals opting for this service will receive a specially-designed donor kit which is delivered with instructions. Home donation alleviates the anxiety that may accompany donations in a clinic donation room. This program is ideal for men with cancer or underlying subfertility; pre-vasectomy patients who may want to cryopreserve in advance of their vasectomy; men with a desire to insure potential future fertility and military personnel going on long-term deployment.

Those interested in exploring this service can speak with a specialist who will walk them through the process in detail. He or she will acquire the necessary information and accept a credit card payment for the service during the conversation. The specialist with then contact Path-Tec, a company specializing in sample collection, and request they send a sample-collection kit. This kit contains collection materials, complete instructions and some additional forms that require signatures. Once the sample is collected, it is returned to the Andrology Lab. Tests will be conducted and results will be reported quickly.

Cleveland Clinic offers two means of donating sperm, both of which require referral from a physician and completion of the appropriate paperwork. In additional to home sperm banking, a donor can visit the Andrology Laboratory and Reproductive Tissue Bank in the Glickman Urology and Kidney Institute on Cleveland Clinic’s main campus. Following completion of the appropriate paperwork, he will complete the donation process in private in a room designed for that purpose.

Your patients can call 1.866.922.6546 (866.9BANKIN) Monday – Friday, 7:30 a.m. – 4 p.m., ET, to speak with a specialist about the NextGen Home Sperm Banking Service.


Bariatric Surgery Now Standard Treatment for Morbidly Obese Diabetic Patients

In March 2011, the International Diabetes Federation (IDF) issued a position statement upgrading bariatric surgery from an option to a priority for morbidly obese patients (BMI > 35 kg/m2) with type 2 diabetes mellitus (DM).

“The value of bariatric procedures in helping morbidly obese patients achieve glycemic control has been confirmed. It is time for metabolic surgery to be an accepted option, because diabetes in severely obese patients is often refractory to conventional therapy with insulin and oral agents, due to severe insulin resistance,”explains Philip Schauer, MD, Director of the Cleveland Clinic Bariatric and Metabolic Institute and a member of the IDF expert panel that authored the position statement.

The IDF statement also says that patients with a BMI of 30–35 kg/m2 should be considered for surgery when hemoglobin A1c is > 7.5 percent despite optimal therapy, and particularly if weight is increasing or in the presence of other weight-responsive co-morbidities that are not achieving targets using conventional therapies, including hypertension, dyslipidemia and obstructive sleep apnea.

The IDF writing group reviewed the data related to other conventional, standard bariatric operations and novel interventional procedures and considered gastric banding, sleeve gastrectomy, gastric bypass, biliopancreatic diversion and duodenal switch in its clinical recommendations.

To have patients evaluated for bariatric surgery at Cleveland Clinic's Bariatric and Metabolic Institute, call 216.445.2224 or 800.223.2273, ext. 52224.


Case Study: Why Emergent Evaluation is Critical for Lung Transplantation

By Marie Budev, DO, MPH

Presentation:

A 55-year-old male with no prior smoking history who recently underwent a video-assisted thoracoscopy (VAT) for evaluation of progressive interstitial infiltrates was emergently transferred from an outside hospital via Cleveland Clinic Critical Care Transport’s fixed wing to the Cleveland Clinic for rapid evaluation for lung transplantation for severe hypoxemia due to progressive interstitial pulmonary fibrosis. Prior to this, the patient had been extremely active and it only had symptoms of a mild cough. He had recently seen his primary care doctor who diagnosed him as having bronchitis and treated him with antibiotics, steroids and inhalers. Shortly after initiating therapy, he began to have worsening dyspnea at rest and was admitted to an outside hospital for further evaluation. Subsequently, CT chest revealed extensive interstitial fibrosis with subpleural reticulation and honeycombing radiographically, consistent with the diagnosis of usual interstitial pneumonitis (UIP). The patient underwent a left-sided lung biopsy and shortly thereafter became hypoxic and was transferred to the medical intensive care unit where he was maintained on high flow oxygen device. The patient also was treated with IV antibiotics steroids and did not improve. Forty-eight hours later, the decision was made to transfer the patient to Cleveland Clinic for emergent transplant evaluation for refractory hypoxemia due to his exacerbation of pulmonary fibrosis.

Examination and Diagnosis:

Physical exam revealed a middle-aged male in severe respiratory distress on 100 percent high-flow mask with a respiratory rate of 44 breaths per minute. On auscultation, bilateral dry crackles were noted on inspiratory and expiratory excursion of the chest. He was also noted to have clubbing of both his fingers and toes on exam. Lung transplant evaluation was initiated on arrival. The patient underwent an emergent right and left heart catheterization, which yielded no evidence of coronary disease but presence of moderate pulmonary hypertension with a mean pulmonary artery pressure 50 mmHg. The patient's CT chest was reviewed, which was radiographically consistent with the diagnosis of UIP. Lung pathology from his VATS biopsy were also reviewed and were consistent with the diagnosis of UIP. Within 48 hours of arrival, the patient continued to decline and was intubated and maintained on mechanical ventilation with an FiO2 100 percent.

Treatment:

The patient underwent a sequential double lung transplant, bridged by mechanical ventilatory support, successfully four days after he was transferred from an outside hospital to Cleveland Clinic.

Outcome:

After two to three weeks, the patient was discharged from the hospital on no supplemental oxygen. Although the patient did have some side effects due to his immunosuppressive medications, he overall stated that his breathing and quality of life is significantly improved after the transplant.

Discussion:

Over the last three decades, lung transplantation has evolved to being considered standard of care for select patients with advanced and disabling lung disease. IPF now represents the leading indication for lung transplantation in the United States. Listing for transplantation should be considered when the lung disease has advanced to a disabling and potentially life-threatening stage. Although early referral to a transplant center is encouraged so that families as well as patient can familiarize himself with the transplant team and process, this may not always be possible in certain disease states – especially pulmonary fibrosis, which can progress at a rapid clinical trajectory leading to a potentially life-threatening stage, as with this patient. In this patient's case, ventilatory support was necessary to bridge the patient to lung transplantation when an appropriate organ became available. Ventilator dependence before transplantation has long been recognized as a risk factor for increased short-term post transplant mortality, although it does not appear to adversely impact outcomes beyond the first year. Transplantation of ventilator-dependent patients in the intensive care unit was previously discouraged, but the new lung allocation system in the United States has allowed transplant centers to reconsider this philosophy and assigned to a high lung allocation scores to patients that are maintained on ventilatory support as a bridge to transplant.

Dr. Budev is the Assistant Medical Director of the lung and heart-lung transplant program at Cleveland Clinic. She can be reached by calling 216.444.3194 or email at BUDEVM@ccf.org.