PACEMAKER: July 1996
Iowa's first TMR laser recipient recovers at
home
In retrospect, Irvin Parry knows his decision to drive home on
April 19, 1996, was one big mistake.
Parry, from Cedar Rapids, Iowa, had just completed a four-day
visit to Dubuque where he and other World War II Navy veterans
planned a reunion for those who served aboard the USS Freestone.
A retiree, Parry had suffered from angina (heart pain) for years.
This time it was different. The nitroglycerin pills he took to reduce
the extreme pain simply weren't helping.
"By the time my wife and I got about halfway to Cascade, I had to
pull over on the shoulder of the highway and take another nitro, my
fifth of the morning," he says. "We went on, but after three miles or
so we had to stop at the Fillmore golf course, where they called for
help. It took an ambulance from Cascade only 16 minutes to get me
back to Dubuque. During that time they gave me two more nitro, which
helped, but I still ended up in the hospital."
After being stabilized at Dubuque's Finley Hospital, Parry
transferred to St. Luke's Hospital in Cedar Rapids, where he could
receive care from his long-time cardiologist, M-Naser Payvandi, MD.
"I've already had two heart bypass operations, one in 1975 and
another in 1982," Parry says. "Dr. Payvandi said I couldn't go
through another one. So, unless there was some new technology, there
wasn't much they could do to fix my heart."
Fortunately, a new laser procedure is being evaluated at several
major medical centers, including the University of Iowa Hospitals and
Clinics (Pacemaker, March, 1996). The procedure, called
transmyocardial revascularization (TMR), offers potential benefit to
patients like Parry who cannot be treated by cardiac bypass surgery
or balloon angioplasty.
At the UIHC, Parry was evaluated by cardiologist Ron Oren, MD, and
heart surgeon Wayne Richenbacher, MD, who screen all candidates for
the TMR trial to ensure no other form of therapy could benefit them.
Their evaluation confirmed that Parry was a good candidate for
TMR. Dr. Richenbacher performed the procedure--the state's first TMR
trial procedure--on June 5, 1996.
"Mr. Parry did very well following the operation," Dr.
Richenbacher says. "He returned home after five days in the hospital.
Like all TMR patients, however, Mr. Parry will not experience the
beneficial effects of TMR, such as reduced angina or improved blood
supply to the heart muscle, for three to six months."
During the procedure, Dr. Richenbacher drilled 45 tiny holes in
Parry's left ventricle, the heart's main pumping chamber.
Theoretically, these holes, or channels, allow more oxygenated
blood to flow directly into the heart muscle, thereby reducing
angina.
The concept behind TMR dates back several decades. Recently,
carbon dioxide lasers have been used to perform TMR. Preliminary
results show that TMR with the carbon dioxide laser reduces angina
and improves myocardial perfusion, or the flow of blood into the
heart muscle.
The TMR system being evaluated at the UIHC is similar, but uses a
Holmium laser instead of a carbon dioxide laser. University Hospitals
is only the eighth medical center in the United States where TMR with
the Holmium laser has been performed.
To date, only 20 centers have been approved by the FDA as part of
the clinical trial using the Holmium laser.
Parry says he was initially concerned about the risks associated
with TMR, but is happy he agreed to participate in the study.
"They told me there was an 8 percent mortality rate associated
with it, but that still looked better than if nothing else was done,"
he says. "The people of Iowa just don't realize what a tremendous
asset we have in the University of Iowa Hospitals and Clinics. I've
been saying that for years, and I truly mean it."
Further information about TMR procedures may be obtained from Dr.
Richenbacher at (319) 356-4087 or Dr. Oren at (319) 356-4992.
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Scottish Rite Masons pledge $250,000 to UI's
Alzheimer's care, research
Can a person with Alzheimer's disease drive a car safely?
What can be done to help nursing assistants who experience stress
and burnout from the difficult task of caring for patients with
Alzheimer's?
What can Alzheimer's patients and their families do to manage
memory and behavioral difficulties in the home (see related story on
pages 6, 7)?
These and other vital questions about Alzheimer's disease are
being addressed by neurological disease specialists at the University
of Iowa.
"We at Iowa have a long-standing commitment not only to
researching the causes and consequences of Alzheimer's disease, but
also to the well-being of patients and their families," said Antonio
R. Damasio, MD, Van Allen Professor and Head of the Department of
Neurology. "We feel fortunate that the Scottish Rite Masons of Iowa
recognize the value of this work and its effects on the lives of
thousands of Iowans."
The Iowa Scottish Rite Masonic Foundation and the Iowa Scottish
Rite Masons recently presented a $50,000 check to the Alzheimer's
clinic at the University of Iowa Hospitals and Clinics. It was the
first installment of a five-year, $250,000 commitment to the clinic
through the University of Iowa Foundation.
Addressing guests at a dedication and gift presentation on June
10, UIHC Director and CEO R. Edward Howell announced that the UIHC
clinic that provides care for Alzheimer's patients has been renamed
the Iowa Scottish Rite Masonic Foundation Alzheimer's Clinic.
"This action," Howell said, "underscores the pride and gratitude
we have in a partnership with the Scottish Rite Masons of Iowa to
focus resources and commitment to providing nationally preeminent
health care for Alzheimer's patients and their families."
The impact of Alzheimer's disease is staggering. According to the
Iowa Department of Elder Affairs, approximately 65,000 Iowans
currently have the disease, with that number expected to triple by
the year 2010. The total national cost of Alzheimer's disease exceeds
$1.27 trillion. Because health insurers generally cover less than 10
percent of that cost, Alzheimer's patients and their families
typically bear a tremendous financial burden.
In reflecting on these statistics, Harry Barrows, sovereign grand
inspector general of the Iowa Scottish Rite Masons, said the gift
recognizes the magnitude of neurologic disease, and role the UI plays
in serving the state's Alzheimer's patients.
"Like all Iowans who know anything about the University of Iowa,"
Barrows said, "the Scottish Rite Masons are immensely proud of the
university. We feel there is no better way to invest money and time
than to support the university's work in this field."
Charles Howard, president of the Iowa Scottish Rite Masonic
Foundation, jointly presented the Scottish Rite Masons' check with
Barrows.
Howard said, "Because of the large number of elderly people in
Iowa, we feel it is extremely important to support the UI Alzheimer's
clinic."
The Masons' gift will enable the UIHC to consolidate its
multidisc-iplinary Alzheimer's services, which encompass neurology
and its subspecialties including neuropsychology (directed by Daniel
Tranel, PhD), neuroimaging (Hanna Damasio, MD), and nursing care,
(Geri Hall, PhD candidate).
"Thanks to the Masons' generosity, this team and its vital patient
care and research missions soon will be coordinated by a highly
qualified specialist," Dr. Damasio said. "We're in the process of
recruiting to fill this new position now."
UI researchers have achieved significant Alzheimer's advances,
notably in the fields of neuroanatomy and neuropathology. Major UI
breakthroughs included new insights into which parts of the brain are
damaged by Alzheimer's disease, a study showing preserved motor
learning in Alzheimer's patients, and the development of a new
Alzheimer's treatment based on biofeedback. Ongoing research by
Matthew Rizzo, MD, is addressing the problem of driving using the
Iowa Driving Simulator.
"With support from organizations like the Masons, we can build
upon our successes of the past," Dr. Damasio said. "We're excited by
the potential for significant advances in research and patient care
during the coming years."
Membership in the Scottish Rite Masons totals approximately 10,000
in Iowa. The group's affiliates, called Valleys, are located in
Clinton, Cedar Rapids, Davenport, Des Moines, and Sioux City.
This year's gift is not the organization's first. Scottish Rite
Masons have supported an Alzheimer's disease fellowship in the
Department of Neurology (a gift of $25,000 annually); supported the
Department of Nursing's production and statewide distribution of a
media packet for caregivers consisting of a video and learning guide
on the basics of in-home Alzheimer's care; supported a series of
seven training seminars for nursing assistants and family caregivers;
and have made an annual gift to the UI's Wendell Johnson Speech and
Hearing Clinic.
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Behavioral techniques may help patients
compensate for memory loss
Bob practiced medicine for more than 30 years, providing expert
care and treatment to hundreds of patients.
Tom is a private pilot who spent much of his professional career
working for manufacturers of aircraft or aircraft guidance systems.
Both men, now retired, share a frustrating, ironic condition.
Despite productive professional lives punctuated by attention to
detail, Bob and Tom (pseudonyms for two people who prefer to protect
their confidentiality) have short-term memory loss.
Bob's professional life began to unravel when relatively small
things, like repeating information on patients' charts, became
noticeable. The information wasn't wrong, it simply appeared twice.
Colleagues brought this behavior to Bob's attention, leading to an
evaluation by a psychologist.
When the psychologist diagnosed Bob's short-term memory loss, he
promptly resigned, prematurely ending a distinguished career.
"I was very grateful to my colleagues for pointing this out to
me," Bob says. "The last thing I'd want to do is damage anyone."
Tom, meanwhile, has a good memory for things in the past,
according to his wife. "It's the short-term memory that's caused a
few problems, enough to annoy me," she says. "Sometimes I have to
remember I can't tell him a series of things to pick up at the
grocery store, for instance, even if I write them down. If I make it
too complicated, something won't be right."
Fortunately, both men have benefited, in varying degrees, from a
short-term memory loss study being conducted at the University of
Iowa Hospitals and Clinics.
Through the study, patients with short-term memory loss associated
with Alzheimer's learn techniques to help them keep their focus.
"These are primarily self-treatment techniques," says Julie Suhr,
PhD, a UIHC neuropsychologist affiliated with the UIHC's Iowa
Scottish Rite Masonic Foundation Alzheimer's Clinic. "Many patients
tend to become uncomfortable in social situations because they
tighten up, and stay tense, from memory loss problems."
Dr. Suhr says the study takes advantage of a preserved type of
memory-motor memory-a skill that is often preserved in patients with
Alzheimer's, even when the disease impairs other memory processes.
"We use motor memory skills to assist in compensation of memory
and other cognitive problems, as well as in the management of
behavioral and psychiatric symptoms that frequently arise in patients
with Alzheimer's disease," Dr. Suhr says. "Preliminary results have
been promising, for both memory performance in the laboratory and for
changes in memory and behavior problems in everyday life."
Bob says the techniques he practices at home have helped him
remember better. "I'm still learning how to do it," he says. "I have
to consciously relax and then practice these techniques during the
day."
Tom says he practices the techniques once or twice a day.
"It certainly makes me feel better," he says. "I feel it's
something that helps keep my interest up and keeps me busy doing
something worthwhile."
Dr. Suhr's research is supported by federal funding from the
National Institutes of Health to the University of Iowa Center on
Aging. Questions about the short-term memory loss study may be
addressed to Dr. Suhr at (319) 356-2671.
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Illinois infant overcomes 'roller coaster'
prognoses
They don't build roller coasters like the one the Montooths have
been riding.
The initial anticipated climb was a nine month pregnancy ending
July 11, 1995 with the birth of a seemingly healthy baby boy-Dylan
Montooth. But at age five months, the Stronghurst, Illinois, infant
entered Burlington (Iowa) Medical Center with life-threatening
pneumonia. Burlington Pediatrician James Hendrix, MD, referred Dylan
to the Pediatric Intensive Care Unit (PICU) at the University of Iowa
Hospitals and Clinics, where he also was diagnosed with severe
combined immunodeficiency syndrome (SCIDS).
"It was weird because just one week before all this began I was
watching him sleep in the swing and thought 'how lucky we are to have
such a healthy baby,'" says Dylan's mother, Peggy.
Peggy and her husband, Bob, were told that if Dylan survived the
pneumonia, he would need a bone marrow transplant to reverse the
life-threatening immunodeficiency syndrome. Of the 4 million births
in the United States each year, immune deficiencies like Dylan's
occur among approximately 150, says Michael Trigg, MD, Professor,
Department of Pediatrics and Director of the Pediatric Bone Marrow
Transplant Unit. Dylan lacked the ability to produce T-lymphocytes, a
component of the blood responsible for ridding the body of
infections. Without T-lymphocytes, fungal and viral infections are
fatal.
"Bone marrow transplants are successful in about 70 percent of
these cases," Dr. Trigg says. On December 22, 1995, Dylan received a
portion of his father's bone marrow in hopes that it would grow and
give Dylan the vital T-lymphocytes he was missing.
Following the transplant, the Montooths' hopes soared again, but a
serious lung infection put Dylan back in the PICU on life-support
equipment. He recovered after three weeks of specialized care.
"That was scary," Peggy says, "but really, the worst was yet to
come."
On March 2, 1996, Dylan's heart stopped beating and he was rushed
from the Pediatric Bone Marrow Transplant Unit to the PICU for the
third time. Dylan had a heart block, or a cardiac conduction defect,
that might have been caused by his ongoing 'graft vs. host' disease,
says Frederick Goldman, MD, Assistant Professor, Pediatrics.
Pediatric cardiologists equipped Dylan with a pacemaker, but his
heart muscle was very weak.
"It was very difficult," said Peggy. "You build up so much, you
get so far, and then something tears it all apart. We'd been told we
could lose him before, but this time we had to consider taking him
off life support."
For days, the Montooths discussed their options with physicians.
Dr. Goldman encouraged them not to give up, saying that he'd seen
Dylan pull himself out before.
"I did not strongly believe in God before this," Peggy says. "But
I thought, 'If God wants to take him because He knows he's going to
suffer the rest of his life, then I'm just glad He's going to take
him so he can be at peace.'"
But Dylan had another agenda. One day, as suddenly as it had
stopped, his heart started beating on its own again.
"I don't think I've taken care of anyone as sick as Dylan who
survived," says Dr. Goldman. "He was on a ventilator three different
times. It was very trying for us as physicians as well as for the
family."
With the help of his father's bone marrow, Dylan began to develop
an immune system and his condition continued to improve.
"The bone marrow transplant was successful, although he's not out
of the woods yet," Dr. Goldman says. "He needs to stay on medications
that will prevent infections and drugs that will prevent 'graft vs.
host' disease, a complication of marrow transplants."
On April 18, 1996, Dylan returned home. A community fund-raiser
helped equip the Montooth's home with special air purifiers and when
he is outside the house, Dylan must wear a surgical mask to help
avoid infections. But the Montooths believe the end of the ride is in
sight.
"Home seems like home again," says Peggy. "It's been a roller
coaster, that's for sure. Sometime you're up the hill and on top, and
then you're screaming back down again. We've learned a lot-things we
knew very little about we now can appreciate. It's just great to have
him home."
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Improved outlook for patients with lethal
brain tumors
As far as Pamela Huppert is concerned, the baseball-sized tumor
surgeons removed from her brain traces all the way back to her
childhood.
Huppert, 44, recalls seeing double on the blackboard as a
13-year-old junior high school student.
"They thought I was having vision problems, so I got glasses," she
says. "As time went on, I began having small seizures that eventually
became big seizures. The first big one occurred after I graduated
from high school."
Doctors diagnosed the epilepsy, and treated Huppert accordingly
over the years. Her husband, Patrick, says, "We just never felt that
the medications she took did for her what they were supposed to do.
We knew something was wrong, but we didn't know what."
Last year, Huppert's problems worsened. Without knowing it, she
had lost her left side vision.
"I began to notice that people were honking at me a lot," she
says. "When I drove, there was a fuzzy road and a clear road.
Fortunately, I knew enough not to take the fuzzy one. But I really
didn't understand it at the time."
Huppert, from Fort Madison, Iowa, finally consulted a Burlington
ophthalmologist to have her eyes examined. He referred her to the
University of Iowa Hospitals and Clinics, where ophthalmologists and
neurologic disease specialists diagnosed her with a large, primary
malignant brain tumor. Following extensive testing, neurosurgeons
removed the tumor.
"When they told us what it was," Patrick says, "we just hugged
each other and cried. It was such a relief to finally know what was
wrong, even though we didn't want the problem to be a tumor."
Todd J. Janus, PhD, MD, Assistant Professor in the Department of
Neurology, has managed Huppert's ongoing neuro-oncologic care. Dr.
Janus says the long-term prognosis for patients with brain tumors
continues to be grim, but that substantial progress has occurred in
recent years.
"With recent advances in radiotherapy and chemotherapy, we're
seeing improved quality of life, as well as quantity of life in many
cases. Some patients are surviving up to five or six years."
In Huppert's case, treatment has included radiotherapy and
chemotherapy treatment on a protocol sponsored by the National Cancer
Institute, and a test drug, temazolamide, undergoing testing for FDA
approval.
The key to effective brain tumor treatment lies in a correct
diagnosis of the tumor's type, Dr. Janus says. The UIHC's
multidisciplinary brain tumor treatment team-which includes
neurologists, neurosurgeons, oncologists radiologists, and specially
trained nursing staff-specializes in treating patients with brain
tumors of all types.
In addition to standard therapies, the team provides patients with
opportunities to participate in investigational drug trials. These
studies, some of which are coordinated through the General Clinical
Research Center, are performed in collaboration with Raymond Hohl,
MD, PhD, Assistant Professor in the Departments of Internal Medicine
and Pharmacology. Current studies include:
-Post radiation therapy study of DFMO-PCV versus PCV chemotherapy
for the treatment of patients with malignant gliomas.
-Recombinant interferon-beta as a single agent and cis-retinoic acid
plus recombinant interferon beta for patients with recurrent primary
malignant gliomas.
-Lovastatin in combination with CCNU, procarbazine and vincristine in
patients with malignant primary brain tumors.
-Continuous infusion of carboplatin, 5-FU with alpha-interferon in
patients with recurrent malignant primary brain tumors.
-Temazolamide to treat patients with malignant gliomas at first
relapse.
-Marimastat to treat patients with newly diagnosed glioblastoma
multiforme.
Dr. Janus is also participating in two programs with the Radiation
Therapy Oncology Group, in collaboration with Radiologists B-Chen
Wen, MD, and Nina Mayr, MD. They are:
-Combined multi-modality treatment for primary central nervous
system lymphoma.
-A comparison of radiation alone versus pre-radiation chemotherapy
for pure and mixed anaplastic ologodendroglioma.
The UIHC's Neuro-Oncology group is also developing new chemotherapy
treatments for patients with metastatic disease to the brain or
spinal cord.
"We've made a lot of progress in the last decade, in part because MRI
technology has provided better information about treatment effects
and response for brain cancer patients," Dr. Janus says. "A cure
remains an elusive goal, but the opportunities for a longer, better
life are improved."
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Collaborative drug monitoring improves patient
care, cuts costs
On a sultry summer morning, a University Hospitals physician
reviews the medication orders for a 22-year-old construction worker
from eastern Iowa.
The patient, a diabetic, has been hospitalized three days with a
complex urinary tract infection. As the physician ponders the
patient's status, a clinical pharmacist arrives to confer about the
patient's condition.
Noting that laboratory test results indicate the patient's kidney
function has decreased slightly, the physician and the pharmacist
agree to order a therapeutic drug assay for the antibiotic the
patient is receiving.
This assay will monitor the amount of the medication in the blood,
allowing clinicians to adjust the dose to ensure effective treatment
without causing adverse health effects or toxicity.
Just before the next scheduled dose of antibiotic, the patient's
nurse takes a blood sample to send to the laboratory, where a
"trough" level, or low drug level in the bloodstream, is determined.
After administering the antibiotic intravenously, the nurse waits the
right time-in this case, 30 minutes-then takes another blood sample
to measure a "peak" (highest) drug level.
The nurse carefully records the dosage time and blood sample time
on the Doctor's Order Form for Therapeutic Drug Assay, a newly
created UIHC form for documenting drug administration to the patient.
The nurse then sends the blood samples and order form to the
Pathology Laboratory for analysis.
Several hours later, the therapeutic drug assay results suggest
that the current dose may be too high, based on the patient's
declining kidney function. A smaller dose would prevent adverse
effects.
After conferring again with the physician, the clinical pharmacist
recommends a revised antibiotic dose.
The above scenario describes how the UIHC's Medical staff, and
Pharmacy, Nursing, and Pathology departments collaborate to provide
the best possible drug therapy care to UIHC patients, according to
Alan Mutnick, Senior Assistant Director for Clinical Pharmacy
Practice.
"The use of drugs with narrow therapeutic ranges (in which
toxicity or ineffectiveness can occur if the dose isn't perfect)
often requires drug level assays to confirm whether blood drug
concentrations are too low or too high based on clinical findings,
such as decreasing kidney function," Mutnick says. "It is also
important that a blood sample be taken at the appropriate time.
Failure to do so may render the results useless or lead to
inappropriate care."
In 1989, a UIHC drug use evaluation program review indicated that
more than 60 percent of therapeutic drug assay reports were not
interpretable, primarily because of insufficient information
regarding the dose time and the blood sample time.
To correct this problem, a program for documenting dose time and
blood sample time was initiated for three antibiotics for which a
therapeutic drug assay was most commonly requested. When properly
used, the interpretability of the assay reports increased to 100
percent.
The latest step in this process is the Doctor's Order Form for
Therapeutic Drug Assay, developed by a multidisciplinary team
involving staff from Drug Use Evaluation, Pharmacy, Nursing,
Pathology, Medical Records, and the Medical staff.
In addition to documenting dose time and blood sample time, the
form lists all commonly monitored drugs. It becomes part of the
patient's permanent medical record, so that all patient care
providers can easily obtain the information.
"We believe this system greatly improves the quality of drug
therapy our patients receive," Mutnick says. "Patients may not only
benefit from this system through reduced charges (an estimated total
decrease in charges for serum samples of between $100,000 and
$200,000 per year), but also from less time spent in the hospital. In
addition, it may well have a noticeable impact on patient outcomes
and patient satisfaction as well. It's a real win-win situation for
us."
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Dr. Melanie Dreher named Dean of UI College of
Nursing
Melanie Creagan Dreher, PhD, Dean of the School of Nursing at the
University of Massachusetts, has been appointed Dean of the
University of Iowa College of Nursing, effective January 15, 1997.
Dr. Dreher succeeds Geraldene Felton, EdD, who has been dean of
the College of Nursing since 1981. Dr. Felton, who had planned to
return to the College of Nursing faculty July 1, 1996, has agreed to
remain as dean until Dr. Dreher arrives on campus.
"Dr. Dreher is a well-respected educator and researcher, as
evidenced by the fact that she is currently president of Sigma Theta
Tau International Nursing Honor Society, as well as her deanships at
other prestigious universities," said Henri R. Manasse Jr., UI Vice
President for Health Sciences. "Her background in teaching, research,
service, and administration make her the ideal candidate to lead the
College of Nursing into a new era of health care."
In addition to being named Dean of Nursing, she will hold the
position of Associate Director for Clinical Practice in the
Department of Nursing at the University of Iowa Hospitals and
Clinics.
Dr. Dreher has been dean and professor of nursing at the
University of Massachusetts since 1988. She is also adjunct professor
of anthropology at UMass and holds secondary appointments as
professor of child health with the University of West Indies and as
senior lecturer in public health at Columbia University in New York
City.
She received her bachelor's degree in nursing from Long Island
University in 1967, a master's in anthropology from Teachers College
of Columbia University in 1974, a master of philosophy from Columbia
in 1976, and a doctorate in anthropology from Columbia in 1977.
Dr. Dreher served as Dean of the University of Miami School of
Nursing from 1984 to 1988, then served as visiting professor in the
Division of Nursing in the Massachusetts School of Health Sciences
before being named Dean at the University of Massachusetts in 1988.
