PACEMAKER: December 1995
Annual Review 1995
From The Director
Dramatic transition accelerated at the University of Iowa
Hospitals and Clinics during 1995.
In collaboration with the UI College of Medicine and
community-based physicians in Iowa and western Illinois, the UIHC is
positioning itself for continued service to the Midwest as a premier
provider of patient care, and a prime base for health professions
education and cutting-edge medical research. The transitions are far
from complete, but we now have strategic foundations to provide
flexibility and support for future adjustments to the rapidly
changing environment in which we serve our patients and their
referring physicians, employers, and health insurers.
Realizing that the College of Medicine and the UIHC must be
coordinated and integrated to meet effectively the challenges posed
by the external environment, Dr. Robert Kelch, Dean of the College of
Medicine, and I have developed a structure for joint oversight of all
clinical activities of our two organizations. We call this equivalent
of a Physician Hospital Organization (PHO) the "Clinical Enterprise."
The conceptual framework for this relationship is illustrated on page
ii.
Although managed care patients currently comprise 17 percent of
the UIHC's patient care services, that component of our clinical
services has grown 41 percent during the past year. Because of that
trend, we are modifying our external delivery system to ensure an
adequate volume of patients to support the patient care, teaching,
and research missions that Iowans expect from the UIHC.
To achieve this objective by coordinating activities with
community-based physicians, hospitals and other providers of health
care, the non-profit University of Iowa Health System (UIHS) was
formed with equal funding by UIHC and the College of Medicine.
A UIHS subsidiary, University of Iowa Affiliated Health Providers
(UIAHP), then entered a partnership with the Iowa division of Mercy
Health Services of Farmington Hills, Michigan, the Iowa Health
System, and BlueCrossBlueShield of Iowa and South Dakota to market a
managed care product called Unity Choice.
University of Iowa Health System has also created another
wholly-owned subsidiary, University of Iowa Community Medical
Services (UICMS). This entity is enabling formal affiliations with
community-based physician practices to provide a "hand-in-glove"
relationship between primary care providers and the University of
Iowa's education and tertiary health care resources.
A UICMS subsidiary, University of Iowa Community HomeCare (UICH),
will be developing formal linkages with home health care providers so
that UIHC patients will return to their homes and receive continuing
services within a seamless network of care.
Service to our patients is an appropriate focus to conclude this
summary of 1995. Our emphasis continues to be on enhancing the value
of the health care purchased by patients and their insurers. As we
make major changes in our corporate structure to operate within the
evolving marketplace of health care delivery, our goal is to ever
enhance the value of our services.
Concurrently, as we operate within a competitive marketplace of
health care delivery, we must never lose sight of the fact that we
serve people and their families at times of their greatest needs and
vulnerability. Health care has always held that lofty responsibility
of human service, and we must never let a marketplace environment
distract our focus on that goal.
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Computers enhance physician access to UIHC
resources
Let's say you're a physician in Charles City and you want to
consult with a subspecialist at the University of Iowa Hospitals and
Clinics or access a medical text you don't have in your office.
If you're like most physicians, you'll use a telephone, send a
fax, or perhaps write a letter. You wouldn't think of using a
computer.
That may change in the not-too-distant future. As communication
technology evolves, new opportunities emerge for the University of
Iowa to communicate with physicians and others interested in the UI's
extensive medical resources.
Limited access to select UIHC data is already available. Any
authorized physician with a SecurID card can search University
Hospitals' INFORMM computer system for information about patients
they have referred to the UIHC. Although clinical and administrative
data such as laboratory results and patient visit information are
currently available through this mechanism, plans are under way to
enhance this capability. The Hospital Information Systems Department
is developing a Computer-Based Patient Record to include images and
other data in an electronic medical record.
At present, relatively few community physicians use their
computers to access the UI's medical services, according to James
Flanagan, MD, PhD, Assistant Professor in the Department of Internal
Medicine and Physician Informatics Coordinator with Hospital
Information Systems.
"In the culture of physicians, it's easier to do it the way it's
always been done, on paper," he says. "But we live in a period of
transition. Big changes are inevitably coming that will revolutionize
the medical communication landscape as we know it."
Of immediate interest is a promising new initiative by the
National Laboratory for the Study of Rural Telemedicine, located at
the UI and directed by Michael Kienzle, MD, Associate Dean in the
College of Medicine.
By early 1996, Dr. Kienzle expects the UI to complete construction
of its high-speed telemedicine network connecting six community
hospitals to the UIHC. Physicians in these community hospitals will
be able to walk up to a "user-friendly" computer work station and use
the network resources to secure information on any medical or health
related topic.
"In some cases, providers will be able to view video clips of
patients and surgical procedures," Dr. Kienzle says. "In others, they
might want to receive articles on the topic published in scholarly
medical journals-journals that are often too costly for rural or
community hospitals to purchase."
Physicians will also be able to use electronic mail (e-mail) to
consult with specialists about their patients; send X-ray scans over
the network to be read by radiology specialists at the UIHC; improve
their diagnoses by viewing abnormal X-rays using computer enhanced
three-dimensional images; and confer with UIHC trauma specialists
over an interactive "real-time" computer system.
Two of the community hospitals will be equipped to allow
specialists at the UIHC, local health care providers, and the patient
and family to confer via interactive television.
"This will allow the patient to be seen without having to travel
to a larger medical center that might be a great distance away," Dr.
Kienzle says. "The Telemedicine Resource Center, which administers
the telemedicine program, also plans to train community health care
providers around the state to use telemedicine technologies, help
rural health care providers connect to e-mail and the Internet, and
answer questions from health care professionals and patients and
families relating to telemedicine."
While the rural telemedicine project will link six community
hospitals with the UI, teleradiology services provided by the
Department of Radiology are already available to 14 rural hospitals
in Iowa and surrounding states. In addition to permitting
consultations with UIHC radiology specialists, these services provide
coverage for community radiologists on nights, weekends, and
vacations.
"We can also provide CT or MRI interpretation where expertise is
not locally available," says Wilbur Smith, MD, Professor and Interim
Head of Radiology.
Much of the UI's electronic educational material stems from the
Radiology Department's Virtual Hospital(tm), a continuously updated
digital health sciences library stored on computers and available 24
hours a day. Developed by Jeffrey Galvin, MD, Associate Professor in
the Department of Radiology, it provides invaluable patient care
support and distance learning to practicing physicians and other
health care professionals.
"Physicians can use the Virtual Hospital(tm) to answer patient
care questions, thus putting the latest medical information at their
fingertips," Dr. Galvin says. "This same information may be used for
Continuing Medical Education, a real plus for all physicians,
especially those in rural areas."
The Virtual Hospital's(tm) multimedia textbooks initially were
linked to the Iowa Communication Network (the statewide fiber optic
system) and available on the Internet through the World Wide Web.
More recently, the Virtual Hospital(tm) also became accessible via
the UI's rural telemedicine laboratory project.
Other technological innovations will fuel additional changes in
the years ahead. So far, the state's fiber optic system has proven
useful as an extremely fast and efficient method for various
information exchanges, including "teleconferences" (video and voice
exchanges between groups of people at two or more distant sites,
using television monitors).
But fiber optic cable-hair-thin glass or plastic fibers capable of
transmitting digital information at the speed of light-is too costly
for widespread use in rural hospitals and physician's offices. Beyond
certain major fiber optic "hub" sites, other high-speed technologies
will be used to link to the Iowa Communication Network for health
care applications.
What if these same complex signals could somehow be transmitted
over existing telephone lines? If this occurs as expected (a major
phone company recently announced new technology to make it possible),
any home or office with a telephone could send and receive video and
audio signals via computer.
"A system of this type would open up a new world of
possibilities," Dr. Flanagan says. "Electronic video, voice, and data
transmission would be possible at any site, no matter how remote. A
physician in the far reaches of Alaska could access the same data as
a physician in Iowa City or Chicago or Berlin."
Dr. Flanagan adds that yet another breakthrough, a software
technology permitting secure transmission of confidential data such
as credit card numbers over the Internet, is already available to
technologically sophisticated users. "When this software becomes
easily available to the average user, it will dramatically change the
way the Internet is used," he says. "It could mean, for instance,
that Dr. Galvin would be able to negotiate with any textbook
publisher to include costly textbooks in the Virtual Hospital(tm).
Right now there's no financial incentive for publishers to make large
texts available on the Internet, because access is free. With a
secure way to protect access and bill people for just the information
they want, it would suddenly become a more attractive proposition."
Dr. Flanagan believes these evolving changes in communication
technology will revolutionize the "paper culture" as we know it. "For
rural physicians, especially, it's going to place a whole lot more
information at their fingertips than ever before."
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Pallidotomy--a breakthrough for people with
Parkinson's disease
Grace Sible knew the end of her teaching career was at hand when
she could no longer write her name on the blackboard.
That was in 1988. She retired from teaching the next year, at age
51. Since then, Sible has experienced even more indignities from
Parkinson's disease, a chronic progressive nervous disease marked by
tremor and weakness of resting muscles and by a peculiar gait.
Drug therapy helped for a time, but not enough. When further
benefit from medication seemed unlikely, Sible's neurologist at the
University of Iowa Hospitals and Clinics, Robert L. Rodnitzky, MD,
Professor and Vice Chair of the Department of Neurology, suggested
she might be a candidate for pallidotomy, a widely publicized type of
neurosurgery that sometimes produces dramatic results.
Patrick W. Hitchon, MD, and Kenneth A. Follett, MD, Professors in
the UIHC Division of Neurosurgery, explain that people with
Parkinson's disease experience overactivity of the globus pallidus
-there's one on each side of the brain-because their brains don't
produce enough dopamine.
During the pallidotomy procedure, surgeons thread a probe deep
into the brain and burn out a sliver of hyperactive neurons in one or
the other, or both, pallidums. In theory, this action interrupts the
brain's malfunctioning circuitry.
A growing number of neuromuscular specialists believe the
procedure helps some patients by reducing muscle rigidity and
providing long-lasting tremor relief.
Early attempts at pallidotomy during the 1950s and 60s seemed
encouraging, but the results were inconsistent and unpredictable. The
procedure quickly became discredited, and remained so until recent
technical changes in the operation and improved brain imaging with
magnetic resonance imaging or CT scans.
Dr. Rodnitzky remains cautiously optimistic about the potential of
pallidotomy to help patients like Sible.
"For all the sensational things that have been published in the
popular media, pallidotomy still isn't a cure. Although it benefits
most patients, sometimes it doesn't help at all," he says. "The
procedure's risks include bleeding in the brain, which fortunately is
rare. And we don't yet fully understand exactly how it works, when it
does."
Nevertheless, Drs. Rodnitzky and Follett believe there is
sufficient evidence to suggest that pallidotomy helps patients who no
longer benefit from medications like L-dopa, the most common drug
therapy for Parkinson's disease. While L-dopa relieves symptoms, it
sometimes becomes less effective over time and may cause serious
side-effects.
"We'd all like to believe there's a miraculous cure on the horizon
for Parkinson's disease, but that's highly unlikely," Dr. Rodnitzy
says. "Even in the select group of patients who qualify for
pallidotomy, not everyone responds equally. Agewise, patients below
age 70 appear to experience the best results."
Sible, 58, believes she has benefited noticeably from the
procedure, which was performed August 4, 1995, by Drs. Hitchon and
Follett.
She can now walk half a mile, as compared to only being able to
walk across a room before the procedure. "You can't believe the
difference, you really can't," says Howard Sible, Grace's husband.
Drs. Hitchon and Follett note that during pallidotomy, patients
remain awake to permit neurologic testing. To prevent movement, the
patient's head remains fixated in a stereotactic frame.
To assure pinpoint accuracy in placing the probe, the UIHC
pallidotomy team relies on MRI images of the brain and recordings of
the electrical activity of single nerve cells in the brain. Patients
are quizzed throughout the procedure, testing for alertness, vision,
motor skills, and speech.
"The procedure requires three or four hours to complete, and
patients must remain still during this time," Dr. Follett says.
"Nevertheless, most patients tolerate the procedure well, and many
experience noticeable improvement before the procedure is even over."
Anyone with questions about the UIHC's pallidotomy service may
call Dr. Rodnitzky at (319) 356-8754, Dr. Hitchon at (319) 356-2775,
or Dr. Follett at (319) 356-2771.
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Dad's loving gift keeps daughter alive
Leslie Hancock hardly knew she was sick.
The six-year-old daughter of Jim and Wendy Hancock of Dubuque,
Iowa, acted like any other healthy, happy kindergartner at Dubuque's
Bryant Elementary School.
But Leslie's parents, and liver specialists at the University of
Iowa Hospitals and Clinics, knew that time was not on her side.
Leslie has cystic fibrosis, a hereditary disease that usually appears
in early childhood and is commonly associated with lung problems.
Abdominal problems sometimes occur, too, and that's been Leslie's
biggest problem since birth.
"Her lungs are fine, but she's had abdominal fluid caused by
cirrhosis (hardening of the liver, a consequence of cystic fibrosis)
three times and she's been hospitalized a lot with other bowel
troubles-four times this year alone," Wendy says.
These continuing problems reached a pinnacle this summer when
transplant specialists at the University of Iowa Hospitals and
Clinics decided that Leslie required a liver transplant soon to
survive.
Jim Hancock, a 38-year-old mechanic at FDL Foods in Dubuque, had
no idea at the time he might provide the liver tissue to save his
daughter's life. "When they first started talking about it, I didn't
know they could use a portion of my own liver for the transplant," he
says. "When the subject of a living-related transplant came up, I
never had to think about it. It was just something I wanted to do."
Living-related liver transplants enable patients like Leslie to
bypass the nationwide acute shortage of donor livers, according to
Maureen Martin, MD, Associate Professor in the Department of Surgery
and Director of Organ Transplantation at the University of Iowa
Hospitals and Clinics. "Approximately 6,000 American patients are
awaiting liver transplants," she says. "Although many adults will die
waiting for a donor organ, the problem is especially critical for
children because of their small size and the need for suitable
donors."
Dr. Martin and You Min Wu, MD, Assistant Professor of Surgery, and
Tonya Oyos, MD, Assistant Professor in the Department of Anesthesia,
performed Leslie's transplant on November 9, 1995. It was the first
time a patient in Iowa had received a liver transplant using liver
tissue from a living, related donor. The transplant required two
separate procedures. In the first, Drs. Martin and Wu, in concert
with Steve Lillehaug, MD, Assistant Professor of Anesthesia, removed
the left lateral lobe of Jim's liver. Then they implanted this liver
section into Leslie's abdomen.
While the amount of Jim's liver needed for transplant was less
than one-quarter of the entire organ, it was more than sufficient for
Leslie's needs. Transplanted livers grow as children age, so no
further procedure should be necessary to ensure Leslie's continued
healthy liver function.
After the procedure, Leslie was watched carefully in the Pediatric
Intensive Care Unit by James A. Royall, MD, Associate Professor in
the Department of Pediatrics and Director of the PICU, and Warren
Bishop, MD, Assistant Professor of Pediatrics, before moving to a
general pediatrics unit and then returning home. Jim went home the
week following Leslie's transplant.
Dr. Wu says, "It takes a couple of months to recuperate, but his
long-term health should not be affected." He adds that Leslie's
cirrhosis is unlikely to recur in the newly transplanted liver.
Meanwhile, the Hancocks hope to have Leslie back in school after
the Christmas break. During the interim, she'll receive
home-schooling through her teachers at Bryant Elementary School, and
entertain herself with paper, scissors, glue, and Crayons.
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New Services and Technologies
NEW IN '95
The University of Iowa Hospitals and Clinics continuously
updates its expertise and technology to provide patients with highly
specialized as well as family-centered, primary health care services.
Our annual summary of new services and innovations lists descriptions
under headings of clinical departments or those specialized care
centers that integrate several medical specialties to focus on a
single disease.
CLINICAL SERVICES
Anesthesia
Hyperbaric Medicine
A new hyperbaric chamber began serving patients on July 31, 1995. The
new chamber permits simultaneous treatment of up to six seated
patients, two patients on stretchers, or a combination of three
seated patients and one stretcher patient. This increased capacity
improves treatment scheduling and reduces patient waiting time.
Clinical Cancer Center
Drug trials
Cancer specialists in the John and Mary Pappajohn Clinical Cancer
Center are evaluating several new drugs, including a phase III trial
of interferon versus cis-retinoic acid and interferon in patients
with metastatic renal cancer; a phase III trial of CD8+ TIL cells and
interleukin II in patients with metastatic renal cell carcinoma; a
phase I and II trial of intravesical gallium nitrate and systemic
paclitaxel in patients with locally advanced bladder cancer; a phase
II trial of deferoxamine and gallium nitrate in patients with
hormone-refractory metastatic prostate cancer; and a phase III trial
of casodex versus observation in patients with pathologic stage C
prostate cancer.
On-line information
Physicians, nurses, patients, and families can now retrieve current
information on cancer topics via on-line computer services provided
by the UI Cancer Information Service. UIHC staff using on-line
databases such as the Physician Data Query can access current
statements from the National Cancer Institute on cancer sites,
topics, and treatment options.
Patient education assistance
Staff at the UI Cancer Center wrote and developed new educational
materials, including a publication on Myelodysplastic Syndromes that
was underwritten by the Leukemia Society of America. Other
publications on hematological disorders include Essential
Thrombocythemia; Idiopathic Myelofibrosis; Idiopathic
Thrombocytopenic Purpura; Waldenstrom's Macroglobulinemia, and
Polycythemia Vera.
Clinical Outreach
The Joint Office for Clinical Outreach Services and Contracting
for Patient Care started 21 new outreach clinics during 1995,
bringing the total number of clinics or programs serving patients
throughout Iowa to 69 and, for the first time, western Illinois:
Dermatology
Skin specialist Richard Caplan, MD, staffs a new UIHC Dermatology
Outreach Clinic twice a month at the Fort Madison Community Hospital
in Fort Madison.
Hematology/Oncology
Charles Riggs, MD, provides monthly hematology/oncology services at
the Van Buren County Hospital in Keosauqua.
Internal Medicine
Heart patients in Galesburg, Illinois, receive bi-monthly UIHC
cardiac electrophysiology services from James Martins, MD. Jack
Stapleton, MD, staffs an Infectious Diseases Clinic every other week
at Broadlawns Hospital in Des Moines. Patricia Winokur, MD, and Trish
Perl, MD, provide similar services on an as-needed basis at Mercy
Hospital in Iowa City.
Medical Oncology
Robert Dreicer, MD, staffs a UIHC Medical Oncology Outreach Clinic at
Fort Madison Community Hospital.
Ob/Gyn
Jerome Yankowitz, MD, staffs a new UIHC Maternal Fetal Medicine
(high-risk obstetrics) Clinic at the Genesis West Medical Center in
Davenport. Carl Weiner, MD, provides similar services in the office
of Lane Reeves, MD, Cedar Falls. Dr. Yankowitz provides
consultations, ultrasound, and prenatal diagnosis services. Dr.
Weiner provides ultrasound, prenatal diagnosis, and reproductive
endocrinology services. Gynecologists Ann Laros, MD, Ann Steiner, MD,
and Noelle Bowdler, MD, staff a new, weekly General Gynecology Clinic
at the Henry County Health Center in Mount Pleasant.
Otolaryngology
Ear, nose, and throat specialist Nancy Bauman, MD, staffs a monthly
UIHC Otolaryngology Clinic at Fort Madison Community Hospital.
Pediatrics
Larry Mahoney, MD, and Ronald Lauer, MD, staff a monthly Pediatric
Cardiology Outreach Clinic at the Pediatric Center in Cedar Rapids.
The same site hosts a Pediatric Nephrology Outpatient Clinic staffed
by Douglas Weismann, MD, and a Pediatric Rheumatology Clinic staffed
by Mary Jones, MD. Also, Eva Tsalikian, MD, staffs a UIHC Pediatric
Diabetes Clinic at the Keokuk County Medical Clinic in Sigourney.
Residents in Storm Lake now have access to a Pediatric
Hemoglobinopathy Comprehensive Care Outreach Clinic as part of the
UI's Child Health Specialty Clinics.
Psychiatry
Barbara Rohland, MD, provides UIHC psychiatric services at the Van
Buren County Hospital in Keosauqua (monthly) and at the Washington
County Hospital in Washington (bi-monthly). Gerard Clancy, MD, and
Nurse Clinician Betsy Hradek provide weekly psychiatric services to
seriously mentally ill homeless patients at the Emergency Housing
Project in Iowa City. Further expansion of this program to serve
other disadvantaged mentally ill people is planned.
Pulmonary Diseases
Rama Mallampalli, MD, staffs a weekly UIHC Pulmonary Diseases
Outreach Clinic at Ottumwa Internal Medicine P.C. in Ottumwa.
Radiology
David Hussey, MD, directs a UIHC Radiology Oncology Clinic, held four
days a week at the Samaritan Health System South Campus in Clinton.
Also, UIHC radiologists provide weekly on-site X-ray and
teleradiology consult services at the Keokuk County Health Center in
Sigourney.
Rheumatology
George Lawry, MD, staffs a monthly UIHC Rheumatology Outreach Clinic
at the Northeast Iowa Medical Education Foundation in Waterloo.
Digestive Diseases Center
Cost-effective therapy
A clinical pharmacist serves the James A. Clifton Center for
Digestive Diseases. The pharmacist helps physicians select
appropriate and inexpensive medications, and counsels patients to
ensure that they use medications effectively and safely.
Family Practice
E-Mail medicine
A $238,000 grant from the U.S. Department of Public Health is being
used to establish a computer-based electronic mail (e-mail) medical
consultation system in Iowa (Pacemaker, October 1995). Under the
grant, UI Family Practice resident physicians learn to use e-mail as
a tool for consulting with subspecialists. Also, computer terminals
for e-mail consultation are being installed at the Family Practice
Center in the Steindler Building and at the UI's Family Practice
office in Lone Tree, and other practice sites as they are developed
by the department.
Extended hours
As a convenience to patients and to accommodate increased patient
volume, the Family Practice Center in the Steindler Building is now
open until 8 p.m. Monday and Thursday and from 9 a.m. to noon on
Saturday.
Sports Medicine
A new Iowa Sports Medicine service provides a multidisciplinary
approach to patient care for high school athletes involving physical
therapy, athletic training, primary care, and orthopaedic surgery
(Pacemaker, October 1995). The service coordinates health care for
participating local high school athletic teams, and provides annual
pre-participation examinations for interested student athletes.
Talk and Thought
A Talk and Thought discussion group serves Family Practice patients
aged 65 and older who face difficult adjustments in life and who
might have been diagnosed with depression, anxiety, or adjustment
disorders. The group discusses the challenges of advancing age,
including health problems, retirement, leisure, dealing with
children, and relocation. Call Gretchen Schmuch, MSW, at (319)
335-6926 for more information.
Telephone triage
Patients calling the Family Practice Center in the Steindler Building
may now speak directly with a nurse who is specially trained to
answer health care questions. To call a triage nurse, dial (319)
335-8486 and press 2 on a touch-tone telephone.
Hospital Dentistry
Electronic Dental Anesthesia
UIHC dentists use Electronic Dental Anesthesia (EDA) to perform
certain procedures without administering local anesthesia. EDA
produces analgesia using electrical signals and transcutaneous
electrical nerve stimulation. This new technology especially benefits
patients with hematological diseases, where bleeding from dental
injections is a concern.
Internal Medicine
Allergy/Immunology
Staffed by Internal Medicine faculty and offering a full range of
allergy and immunology services, the newly organized
Allergy/Immunology Faculty Clinic provides quick, efficient service
for patients who desire a "private practice" model of care.
Cooperative clinic
A newly organized cooperative Heart Disease and Pregnancy Clinic
treats maternal patients with known or suspected heart disease, one
of the most common non-obstetric complications during pregnancy. The
UIHC patient care team includes cardiologists, obstetricians,
anesthesiologists, and pediatricians. Patients receive care
throughout pregnancy, labor and delivery, and postpartum.
Drug trials
The multidisciplinary heart failure team has introduced new protocols
involving multi-center trials of investigational heart failure
medications. These include vesnari-none, beta blockers, calcium
channel blockers, and IV inotropes.
Health Promotion Clinic
A new Health Promotion Clinic serves people who do not regularly
visit a physician yet still need preventive health care (Pacemaker,
November 1995). Directed by Chris Goerdt, MD, MPH, the clinic is
staffed by an advanced practice nurse and a health promotions
counselor.
Inoue valvuloplasty
Percutaneous balloon valvuloplasty for mitral stenosis using the
Inoue catheter is available for the first time in Iowa at the UIHC
(Pacemaker, June 1995). This innovative, FDA-approved technique has
important advantages over conventional balloon valvuloplasty,
including reduced procedure time, greater control of valve dilation,
and markedly improved patient comfort during the procedure.
Rotoblade catheterization
Recently given FDA approval, rotoblade catheterization removes small
coronary artery lesions (atherosclerotic plaque). The rotoblade
catheter tip, a diamond shaped device coated with tiny diamond
fragments, rotates at speeds up to 20,000 revolutions per minute to
cut through arterial blockage. Because of the high speed and tip
design, debris from the procedure is so small that the body's
reticuloendo-thelial system is able to handle it without ill effect.
Syncope service
A new syncope service provides studies of patients with apparent
neurocardiogenic syncope (fainting spells) in order to reproduce
their symptoms. In certain patients, these studies have been useful
in diagnosing and treating neurocardiogenic syncope.
Trials Center
New and innovative therapies for asthma and allergies are provided in
the Allergy and Respiratory Diseases Clinical Trials Center. These
include leukotriene antagonists, biological response modifiers,
peptide immunotherapy, new aerosol delivery systems, and new
steroids.
Neurology
Neurogenetics Clinic
A newly organized clinic provides genetic testing, options for DNA
testing, and counseling to patients with concerns about inherited
neurologic diseases (Pacemaker, November 1995). The clinic is a joint
effort by the Departments of Pediatrics and Neurology and is directed
by Katherine Mathews, MD.
Obstetrics and Gynecology
Assisted hatching
Assisted hatching of embryos--the chemical dissolution of a small
window in the outer coating of the zona pellucida (shell)--is used in
certain cases to help women with a poor chance for success with
assisted reproduction become pregnant. The gap created in the outer
coating allows the embryo to more easily "hatch" and subsequently
implant. Apart from its routine use in selected fresh cycles, a
randomized prospective trial of its use in cryopreserved embryos is
ongoing.
Embryo adoption
The Center for Advanced Reproductive Care offers certain infertile
couples the opportunity to participate in an "embryo adoption"
program. The program makes available to these couples unused embryos
from former patients who have completed their planned childbearing
and who have consented to allow their embryos to be used by others.
ICSI
The Center of Advanced Reproductive Care successfully introduced a
new in vitro fertilization procedure, called intracytoplasmic sperm
injection (Pacemaker, March 1995). In ICSI, embryologists treat
severe male factor infertility by mechnically injecting a single
sperm into an oocyte (egg).
Incontinence device
The Gynecologic Continence Clinic provides a new non-surgical
treatment for patients with genuine stress incontinence, the Introl
Bladder Neck Support Prosthesis. The device fits in the vagina and
elevates the urethrovesical junction to its normal anatomic position.
Clinical studies indicate a success rate of approximately 80 percent
for the treatment of stress incontinence. The device, as well as
other devices also available in the clinic, provide women with either
a temporary or long-term alternative to surgery.
Private rooms
Remodeling of the Family Centered Maternal and Child Care Unit
provides all obstetrical patients with private rooms during their
maternity stay at the UIHC.
Ophthalmology
Diagnostic test
Ophthalmologists in the Cornea Center achieve rapid diagnosis of
corneal infections with a new polymerase chain reaction test for
Herpes simplex and acanthamoeba. Scientists in the Molecular
Ophthalmology Laboratory and Special Microbiology Laboratories in the
Ophthalmology and Pathology Departments developed the test.
Keratoplasty
Ophthalmologists now use Photorefractive Keratoplasty (PRK) with a
new, solid state laser from Novatec Corporation to treat patients
with low myopia and little astigmatism (-1.00 to -6.00 diopters of
myopia, less than 1.50 diopters of astigmatism). Patients are a part
of an FDA approved clinical trial.
Life quality analysis
Changes in quality of life after corneal transplant are being
evaluated in a new clinical trial. This evaluation will help improve
the selection of patients for this vision restoring surgery and help
patients understand what to expect.
Molecular genetics
Ophthalmologists are using molecular genetic techniques to identify
the chromosomal locations of genes that cause various inherited eye
diseases. In some cases, such as retinitis pigmentosa and Leber's
hereditary optic neuropathy, specific molecular diagnoses can be made
in individual patients.
Optic canal decompression
Orbital surgeons now perform optic canal decompression in some
patients who have lost vision because of head trauma. A small area of
bone around the optic nerve is removed to prevent swelling from
permanently damaging the patient's vision.
. Photoscreening
Pediatric ophthalmologists now use the MTI Photoscreener, an instant
film camera designed to detect eye problems in pre-verbal children.
The camera is used to screen for refractive errors, strabismus (eye
muscle imbalances), and media opacities. The early identification of
these conditions will help physicians treat and prevent irreversible
vision loss.
Orthopaedics
New accommodations
New accommodations for patients requiring orthopaedic care,
rehabilitation, and musculoskeletal radiology services opened in the
John Pappajohn Pavilion in May 1995. The new suite houses the
Orthopaedic Surgery Clinic, Musculo-skeletal Radiology Suite, the
Multidisciplinary Rehabilitation Center, and faculty and staff
offices for Orthopaedic Surgery, Radiology and staff in the
professional offices serving rehabilitation patients.
Total ankle replacement
For certain patients with ankle arthritis, orthopaedic surgeons now
provide total ankle replacement. Orthopaedic surgeon Charles
Saltzman, MD, describes ankle replacement as a promising alternative
to fusing the ankle joint. Candidates for the procedure include older
patients with low activity demands, multiple joint arthritis
involving the ankles, feet, and knees, and those who experience
continued pain despite orthotic treatment. Ankle replacement offers
the patient potential to retain or improve motion and function of the
lower extremity.
Otolaryngology
Adult airway team
A multidisciplinary airway team, chaired by pulmonologist Geoffrey
McLennan, MD, provides assessment and reconstruction for adult
patients with major airway problems.
Cochlear prosthesis
A new cochlear implant prosthesis with a telemetry system devised by
UI investigators permits more appropriate fitting of cochlear implant
technology to patients with profound hearing loss.
Intra-arterial chemotherapy
A new intra-arterial chemotherapy treatment that can be delivered
locally to the tumor with an IV protective agent appears to
significantly benefit patients with advanced head and neck cancer.
The treatment, provided in conjunction with resection surgery, offers
the advantage of delivering high doses of chemotherapy to the tumor
site with fewer side effects.
New implants
Patients requiring prosthetic noses, eyes, and ears may benefit from
the renewed availability of extraoral osseointegrated implants. These
implants had been available earlier at the UIHC on a trial basis, but
were off the market for three years until recent FDA approval.
Pediatric airway team
Pediatric surgeons, pediatric pulmonologists, and pediatric
otolaryn-gologists collaborate to provide a multi-disciplinary
Pediatric Airway Team for children with laryngo-tracheo-bronchial
problems. The team's special phone number is (319) 353-7500.
Pediatrics
ECMO
Pediatricians and surgeons now provide a full extracorporeal membrane
oxygenation (ECMO) program to support neonates, infants, and adults
with impaired lung function. ECMO uses an artificial heart-lung
machine to draw blood from the body, remove carbon dioxide, and add
oxygen before pumping the blood back into the body.
Enzyme screening
The Fatty Acid Oxidation Disorder Laboratory in the Department of
Pediatrics is offering short and long chain fatty acid oxidation
screening and immunochemical protein analysis of several enzymes of
fatty acid oxidation and metabolism. These techniques will allow
easier identification of patients with fatty acid oxidation disorders
and help provide the best possible treatment of patients.
Lymphocyte infusions
The Pediatric Bone Marrow Transplantation Service has introduced a
new program to infuse lymphocytes from bone marrow donors into
recipients to treat serious infections, treat recurrent leukemia by
causing a graft-versus-host leukemia effect, or accelerate immune
recovery. The latter use is critical because it promotes earlier
immune system recovery, thereby reducing infection risks following
bone marrow transplantation. Bone marrow transplant specialists
collect these mature lymphocytes from bone marrow donors at the time
of donation, then place them in storage until needed.
Renal service teamwork
UIHC's Organ Transplantation Service and the Pediatric Renal Service
have collaborated to develop a multi-disciplinary approach to
treating pediatric patients with chronic renal failure. A team of
psychologists, social workers, dietitians, pediatric renal nurse
practitioners, transplant surgeons, and pediatric nephrologists
provides patient care before and after kidney transplantation.
New tumor treatments
The Division of Pediatric Hematology/Oncology now provides peripheral
stem cell transplants for pediatric patients with recurrent brain
tumors. The service also provides interleukin-2 stimulation and
peripheral stem cell rescue for patients with recurrent solid tumors.
A research protocol permits Recombinant Factor VIIa home therapy
treatment for patients with factor VII inhibitors.
Psychiatry
Mood disorders
The Adult Psychiatry Mood Disorders Unit expanded its programming.
Clinical psychologists and advanced practice nurses provide Group
Cognitive Therapy sessions. These sessions offer patients the
opportunity to use the Cognitive Therapy principles included in
training classes taught by staff nurses from the psychiatric units.
Partial hospitalization
A Psychiatric Partial Hospitalization Unit opened in February 1995.
The program treats patients who do not require around the clock
hospitalization, but who do need more care than can be provided in an
outpatient clinic. The new unit is a cooperative effort involving
psychiatrists, nurses, occupational therapists, social workers,
activity therapists, pharmacists, and dietitians.
Radiology
Cervical facet injections
This technique benefits patients with chronic arthrosis and neck pain
caused by degenerative disease of the cervical facets. Injection of
steroids or other anesthetics into the facet often gives long-term
pain relief.
CT reconstruction
Improved techniques in 3-D construction, made possible by new spiral
CT scan, offer patients the opportunity for non-invasive angiography.
The technique shows arterial aneurysms and intracranial vascular
malformations in superb detail. Studies have begun to evaluate CT
reconstruc-tion's potential to replace arteriography in select
situations.
CT fluoroscopy
A new CT fluoroscope permits "real-time" visualization of bodily
structures under CT scan, thereby enhancing biopsies and other CT
guided procedures.
Functional MRI
Functional Magnetic Resonance Imaging is now possible because of
recently acquired rapid MR scanning techniques. Functional MRI
measures blood flow to organs, particularly the brain, and permits
evaluation of heart abnormalities.
New techniques
Pulmonary artery thrombosis (blood clot in an artery to the lungs)
can severely compromise patient quality-of-life. However,
interventional radiologists are using new techniques for lysis of the
clots in pulmonary arteries that enhance patient outcome.
Rapid service
Previously, percutaneous (through the skin) placement of central and
peripheral access lines often required surgery. However, new in-line
placement techniques greatly speed the procedure and permit same-day
service.
Recanalization
Interventional radiologists now provide recanalization of deep venous
thrombosis (acute and chronic) of the lower and upper extremities. In
these instances, patients with long-term leg (or arm) swelling caused
by chronic clots in their veins benefit from a percutaneous technique
that causes blood flow to be re-established in previously clotted
veins.
RTOG protocol
The UIHC Division of Radiation Oncology became an affiliate member of
the Radiation Therapy Oncology Group (RTOG) in 1995. This opens more
than 40 investigational and cooperative treatment protocols to cancer
patients.
Surgery
Antegrade enema
For children and even some adults with anal incontinence, pediatric
surgeons now perform a relatively minor operation to create a
cutaneous appendicostomy or cecostomy in the proximal portion of the
colon using a conventional gastros-tomy button for access. An enema
solution can then be administered directly into the proximal colon,
emptying the colon in an antegrade fashion and preventing accidental
bowel movements.
Craniofacial reconstruction
A multi-specialty craniofacial reconstruction team has been
established by plastic surgeons, neurosurgeons, neurologists,
psychiatrists, and neuroradiol-ogists. Three-dimensional computerized
tomography images are used to evaluate these deformities.
LVAD
Patients with severe circulatory collapse or who are awaiting a heart
transplant can now be supported for extended periods with a left
ventricular assist device (LVAD). The UIHC's first LVAD patient
received a successful heart transplant in May 1995, after being kept
alive for 90 days while on LVAD support (Pacemaker, August 1995).
Lung reduction
Certain patients with emphysema may benefit from lung reduction
surgery, a technique that appears to improve overall elastic recoil
of the lung (Pacemaker, August 1995). In the procedure, surgeons
decrease the size of the lung, either by shaving off a portion of it,
or by folding the lung over on itself and attaching it with staples
or using a laser. At the UIHC, surgeons perform the technique for
patients who are severely short of breath because of overexpanded
lungs.
Single cell recording
Neurosurgeons are obtaining new information concerning human brain
cortex processing of hearing. This new technique uses a recording
from a single neuron using a micro electrode to study the neuronal
activity concerned with interpretation and identification of language
and sounds.
Stereotactic pallidotomy
In this technique, neurosurgeons place small electrical lesions in
the brain to relieve or improve movement disorders in patients with
Parkinson's disease (story on pages 6 and 7).
Urology
Brachytherapy with Pallidium
Urologist James Donovan, MD, and Radiation Oncologist James Wheeler,
MD, are providing collaborative evaluation and treatment of patients
with prostate cancer using highly accurate transrectal ultrasound
guidance for the implantation of radioactive Pallidium seeds into the
prostate.
Expanded infertility services
In July 1995, Jay Sandlow, MD, joined the Urology faculty to support
expanded male factor infertility services. He and James Donovan, MD,
provide microsurgical epididymal sperm aspiration (MESA), which is a
relatively new surgical procedure used in conjunction with in vitro
fertilization for men who have no sperm in their semen.
Neuro-Urology Center
In April 1995, the UIHC opened the new Neuro-Urology Center providing
video urodynamics and biofeedback therapy (Pacemaker, May 1995). The
video urodynamics technology combines fluoroscopy and urodynamics
simultaneously for the most objective and complete evaluation of the
function and anatomy of the lower urinary tract (voiding and
continence). The program is directed by Urologist Karl Kreder, MD,
and Gynecologist Ingrid Nygaard, MD.
Orthoptic urinary diversion
A surgical procedure called orthoptic bladder replacement has been
extended to female patients. In the procedure, urologists fashion the
small bowel into a bladder with connection to the normal ureters and
urethra in patients who have their bladder removed because of cancer
or non-function. This procedure was previously performed only for
men.
Radiographic imaging
Charles Hawtrey, MD, has been developing computer-generated
radiographic images to be placed in patient records to enhance the
information provided to referring physicians, consultants, and
students.
Radioimmunotherapy
A monoclonal antibody (Mab) specific for prostate tissue has been
used successfully by radiologist Daniel Kahn, MD, and urologist
Richard Williams, MD, to determine the site of prostate cancer that
has disseminated. The new protocol uses the same Mab attached to a
radioactive agent (yttrium-90) to treat patients with metastatic
prostate cancer.
Unbound PSA
A new test that measures a sub-category of PSA (Prostate Specific
Antigen) is being performed in the urology laboratory to help
distinguish prostate inflammation and benign prostatic enlargement
from prostate cancer.
Patient Services
Emergency Medical Services
Nitric oxide
In a cooperative effort involving staff from Respiratory Care,
Neonatology, and Emergency Medical Services, the Mobile Critical Care
Unit has been equipped to deliver nitric oxide to critically ill
neonatal patients. Nitric oxide can be used to treat pulmonary
hypertension, a condition that often affects patients with lung
injury, infections, premature birth, and certain heart conditions.
Information Systems
On-line documentation
The first phase of a comprehensive On-line Clinical Documentation
System for capturing and reporting clinical information on the
INFORMM computer system was piloted in selected ambulatory patient
clinics in September 1995. This system helps clinicians track
essential clinical information, including chief complaint,
medications, allergies, and health maintenance data.
Nursing
CJD infection control
In collaboration with the Departments of Neurosurgery, Housekeeping,
Central Sterilizing, and Hospital Epidemiology, UIHC perioperative
nurses have initiated a research-based multidisciplinary protocol for
the perioperative care of patients with Creutzfeldt-Jakob Disease
(CJD), a syndrome caused by a unique infection of the brain. This
protocol is essential, particularly in the operating room, because
the infection is extremely difficult to destroy and highly
concentrated in the brain, cerebral spinal fluid, and optic tissue.
Bladder scanning
New portable ultrasound technology used by Neuroscience nursing staff
allows quick and easy non-invasive assessment of bladder volume.
Occupational Therapy
Education team
The Occupational Therapy Department joined the orthopaedics
pre-surgery education program that helps prepare patients for total
hip replacement surgery. The occupational therapist discusses
adaptive devices and teaches techniques that enhance self-care
independence following surgery.
Pharmacy
Clinical practices
Clinical pharmacist practices were established on five patient care
units (Pediatric Intensive Care Unit, 6JCE, 6JCW, 7JCE, and 7JCW).
Eighteen patient care units are now served directly by clinical
pharmacists who review medication orders, interact with physicians
and nurses to ensure the safe and rational use of medications, and
teach patients how to use their medications properly.
Drug assay requests
Pharmacy staff coordinated a multidisciplinary initiative involving
Medical staff, Nursing, Pathology, and Medical Records to design and
implement the Doctor's Order for Therapeutic Drug Assay, which is
used by prescribers to request serum assay studies. These studies
confirm whether the amount of certain drugs in a patient's
bloodstream is too high or too low. The new order form permits
physicians and pharmacists to better tailor drug therapy to a
patient's specific needs through greatly enhanced interpretation of
the serum drug assay results.
Electronic documentation
A computer-based documentation system permits pharmacists to
electronically record clinical interventions with prescribers and
other health care practitioners, and provides a method for
documenting patient outcomes associated with these interventions.
Respiratory Care
New ventilators
The UIHC acquired 34 Siemens Servo 300 ventilators to serve neonatal,
pediatric, and adult patients. These technologically advanced
ventilators expedite stabilization of critically ill patients,
enhance patient comfort, and promote the ventilator weaning process.
Social Services
Centralized services
Reception and support services for the Patient Representative Program
and the Departments of Pastoral Services and Social Service have been
centralized, to enhance patient/family access to services and to
reduce duplication.
Enhanced service
Clinical social workers now serve patients and families in the
Clinical Cancer Center outreach clinics. Support groups are also
provided at outreach sites.
Return to the top
Howell leads AAMC teaching hospitals during
turbulaent era
R. Edward Howell's leadership of the nation's major teaching
hospitals occurred during one of the most turbulent and challenging
eras in American health care.
During 1994-95, Howell chaired the Council of Teaching Hospitals
(COTH), composed of some 400 teaching hospital members of the
Association of American Medical Colleges. Simultaneously, he was
guiding the University of Iowa Hospitals and Clinics through major
organizational changes and bold new market-driven initiatives as the
UIHC's director and chief executive officer.
"There has probably never been a more intense year in the array
and importance of issues facing the AAMC and its teaching hospitals,"
said Robert Dickler, AAMC Senior Vice President for Health Care
Affairs. "Ed Howell provided thoughtful, stable and forward thinking
leadership in representing the Association and its teaching hospital
members, giving unselfishly of his time in providing leadership in
Iowa and in Washington D.C."
As COTH chair, Howell helped develop and lead strategies to
amplify academic medicine's voice on Capitol Hill. On February 14,
Howell joined other AAMC leaders in addressing news media
representatives at the National Press Club to express concerns
regarding market reform effects on America's teaching hospitals.
Later, he led briefing meetings with Congressional leaders.
On June 28, Howell testified before the House Commerce Health and
Environment Subcommittee about the importance of the Medicare program
in support of academic medicine's patient care and teaching
responsibilities.
During his tenure, he helped develop a consensus among COTH
members to effect a change in the organization's membership
eligibility and name to Council of Teaching Hospitals and Health
Systems. The new orientation to membership reflects major
organizational changes in health care.
