Chesapeake Physician March/April 2016 Issue

Advancing Digestive Disease DETECTION AND CARE

HELPING PATIENTS

BREATHE EASIER

CONNECTED HEALTH AND THE

INTERNET OF THINGS

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CONTENTS

FEATURES

DEPARTMENTS

10

6 CASES

Advancing Digestive Disease Detection and Care

Treating Rectal Cancer, Ulcerative Colitis and Food Allergies The Western lifestyle has contributed to a high incidence of digestive tract diseases. Our medical specialists discuss the latest approaches in treating three common digestive conditions – ulcerative colitis, food allergies and rectal cancer.

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Helping Patients Breathe Easier Learn about the latest diagnostic and treatment approaches for two common conditions that affect your patients’ ability to breathe - chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA).

Bariatric Surgery: Safe and Effective

8 SOLUTIONS

Using Evidence-Based Healthcare Design To Make Buildings Work for Patients

22 POLICY

A Champion for a Healthier Virginia An Interview With Virginia Lieutenant Governor Ralph Northam, MD

26 HEALTHCARE IT

Connected Health and the Internet of Things

31 OUR BAY ON THE COVER: Jennifer McQuade, MD, FACS, FASCRS, colorectal surgeon at Virginia Hospital Center Physician Group.

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P U B L I S H E R ’ S N OT E

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hether you’re an independent physician or part of a regional healthcare enterprise, you’re feeling the pressure for better outcomes and improved care delivery costs. Innovation helps physicians meet those challenges and comes in a variety of forms, from better diagnostic tools to access to critical data to a more patient and user-friendly space in which you deliver care. As we do in every issue, we bring you highlights of our region’s healthcare innovations in the following pages.

In our cover story (p. 10), we talk with medical experts about rectal cancer, food allergies and ulcerative colitis to learn the latest diagnostic and treatment approaches for these gastroenterology conditions.

The Western diet, which is full of processed foods, and high in fat and sugar, most likely plays a significant role in the increased incidence of digestive tract diseases. But diet is not the only culprit. Researchers have uncovered that a combination of genetics and environmental factors also contribute to the prevalence of these diseases. With some 5% of Americans at risk for colorectal cancer, physicians have developed innovative approaches to treating rectal cancer to improve patient prognosis. And as food allergies have increased by 50% in the last nine years, physicians have learned that early exposure to pathogens, except through the skin, is protective. Until we are more successful at preventing these issues, it’s likely that we’ll continue to see a growth in restaurant menus that highlight gluten-free options.

One of my favorite yearly conferences is the annual mHealth conference outside of DC, which I refer to as ‘where Silicon Valley meets patient care.’The emphasis is on engaging patients and providers anytime and anywhere – innovations at every turn. Session topics range from the impact of care delivery, clinical care and patient and consumer engagement to the latest in technologies, research, policy and, of course, the business behind it all. This year’s conference didn’t disappoint and as better reflection of its focus, it’s now named “Connected Health Conference” (p. 26).

Two years into their four-year term, Virginia Governor Terry McAuliffe and Lieutenant Governor Ralph Northam have been on focused on building a healthier Virginia inclusive of the health of its economy and the health of its citizens. In this issue, we sat down with Lieutenant Governor Northam, who still maintains a practice as a pediatric neurologist (p. 22). During his tenure, the Lieutenant Governor has been instrumental in leading an agenda focused on creating access to healthcare, increased funding and access for mental health services and innovation in healthcare via a strategic partnership between Northern Virginia’s largest health system and Virginia’s largest public research university. When the Lieutenant Governor told us about the administration’s Fitbit Challenge, my first thought was,“That makes sense for a team that seemingly doesn’t sleep.” Second thought, “How do I get in on that?!”

To life!

Jacquie Cohen Roth

Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician

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JACQUIE COHEN ROTH FOUNDER/PUBLISHER/EXEUTIVE EDITOR jroth@chesphysician.com LINDA HARDER, MANAGING EDITOR lharder@chesphysician.com OPERATIONS MANAGER Stefanie Jenkins sjenkins@mojomedia.biz MANAGER SOCIAL& DIGITAL MEDIA Jackie Kinsella jkinsella@mojomedia.biz COPY EDITOR Ellen Kinsella CREATIVE DIRECTOR Susan Smerker ssmerker@mojomedia.biz PHOTOGRAPHY Tracey Brown, Papercamera Jay Fleming, Jay Fleming Photography Jay Paul, Jay Paul Photography Keith Weller, Keith Weller Photography Chesapeake Physician – Your practice. Your life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE).

Mojo Media, LLC 1332 Cape St. Claire Rd. #372 Annapolis, MD 21409 443.837.6948 mojomedia.biz Subscription Information: Chesapeake Physician is mailed free to licensed and practicing physicians and a select group of healthcare executives and stakeholders throughout Maryland, Northern Virginia and Washington, DC. Subscriptions are available for the annual cost of $52. To be added to the circulation list, call 443.837.6948.

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Chesapeake Physician – Your practice. Your life.™ Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Chesapeake Physician. Advisory Board members include: RANDY M. BECKER, MD

Advanced Radiology HARRY BRANDT, MD

Sheppard Pratt Health Systems PATRICIA CZAPP, MD

Anne Arundel Medical Center HOLLY DAHLMAN, MD

Green Spring Internal Medicine, LLC MICHAEL EPSTEIN, MD

Digestive Disorders Associates STACY D. FISHER, MD

University of MD Medical Center MICHAEL FREEDMAN, MD

Evolve Medical Clinics GENE RANSOM, JD, CEO

Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO

Shore Health Comprehensive Urology VINAY SATWAH, FACOI

Center for Vascular Medicine THU TRAN, MD, FACOG

Capital Women’s Care Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media, LLC, cannot be held responsible for opinions expressed or facts supplied by authors and resources.

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CASES

Bariatric Surgery: Safe and Effective B Y B A R RY G R E E N E , M D , FA C S , FA S M B S

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CASE RW is a 66-year-old gentleman with a body mass index (BMI) of 54. He presented with poorly controlled diabetes, hypertension, gout, nonalcoholic steatohepatitis, lower-extremity edema, and osteoarthritis, which limited his ability to perform activities of daily living. He had tried many diets over the years and followed up regularly, but his weight continued to slowly rise. He used almost 100 units of insulin daily plus Actos, with poor diabetic control. Exercise was not possible because of immobility related to osteoarthritis and recurrent gout. After an extensive educational program that included support groups, nutritional counseling, psychological assessment, and therapeutic exercise, he underwent surgical therapy for his morbid obesity.

Following surgery, he noted a reduction in hunger. He maintained a lowcarbohydrate diet and saw a rapid resolution of his diabetes. With continued weight loss, his exercise tolerance and quality of life dramatically improved.

Now five years postoperative, he has a BMI of 29. His only remaining medical problem is mild hypertension, which is controlled with low-dose medications.

His tophaceous gout has completely resolved, despite maintaining a diet with 70 grams of protein per day.

DISCUSSION: The majority of obese people diet for years and lose some weight.

However, studies show they usually regain their lost weight eventually.1 Excess weight stops them from enjoying life, being productive citizens and fulfilling their dreams. Obesity causes or worsens diseases such as diabetes, hypertension, dyslipidemia, obstructive sleep apnea, gout, and osteoarthritis. Multiple studies show that associated diseases markedly improve or resolve with the resolution of obesity.2,3 The “Look Ahead” trial, sponsored by the National Institutes of Health, studied in great detail the effects of intensive weight management in 5,000 patients over eight years and showed no decrease in cardiovascular events, and only slight

improvement in diabetic control.4 These results stand in stark comparison to the “Stampede” trial, in which patients with poorly controlled diabetes (hemoglobin A1c > 9%) were randomized to surgical versus medical management.

At three years of follow-up, glycemic control (hemoglobin A1c <7) was seen in more than 30 percent of surgical patients, with no major complications.5 Hypertension and dyslipidemia have also been shown to resolve in more than 60 percent of patients following bariatric surgery. Gout medication was no longer needed in 72 percent of patients following weight-loss surgery.2,3,6,7 The safety of bariatric surgery has improved dramatically over the past two

1 Svelte LP, et al., Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial.

JAMA. 2008 12;299(10):1139-48

5 Schauer, PR, et al., Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 3-Year Outcomes. NEJM 2012; 366:15 67-76

2 Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA. 2004;292(14):1724-1737. doi:10.1001/ jama.292.14.1724

6 Hutter, MM, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011 Sep;254(3):410-20

3 Gloy, V.L. et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. BMJ 2013;347:f5934 4 The Look AHEAD Research Group. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. N Engl J Med 2013; 369:145-154

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7 Tobias, DK. et al. Body mass index and mortality among adults with incident type 2 diabetes. NEJM 2014 Jan; 233–244 8 Breathauer, SA. et al. Bariatric Surgery and Class I Obesity (BMI 30–35 kg/m²). SOARD 2013 Sep:e1-e10

decades. Accreditation of bariatric surgery centers has enhanced quality by requiring extensive training and preparation of staff and hospitals to perform surgery on these complicated patients. The result has been decreased perioperative complications and mortality, and decreased length of stay and readmission rates.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a comprehensive program sponsored by The American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS). Accredited centers undergo periodic rigorous surveys and must submit independently verified, complete data on all patients undergoing bariatric surgery, including followup to a centralized database.

The HIPAA-compliant data is then compared to benchmarks and peers, identifying centers or surgeons that are outliers. Frequent collaboration between centers across the country raises the performance of all centers that participate.

The result has been a 0.11-percent 30-day mortality rate and three percent complication rate at accredited centers.6 Tobias and Associates showed increased mortality in patients with all classes of obesity compared to normal and overweight patients.7 A recent ASMBS consensus statement reviews in greater detail the outstanding advantages of surgical management for all classes of obesity, even those with a BMI of 30.8 Now that bariatric surgery has been overwhelmingly proven to be effective and safe when performed at an MBSAQIPaccredited center, we need to offer bariatric surgery to suitable patients who have not achieved and maintained significant weight and comorbidity improvement with nonsurgical treatment. CP Barry Greene, MD, FACS, FASMBS, is the medical director of Bariatric Surgery at Adventist HealthCare Shady Grove Medical Center, Rockville, Md., and a surveyor for the MBSAQIP. He can be reached at dr.barrygreene@gmail.com.

S AT U R D AY , A P R I L 9 , 2 0 1 6 5 : 3 0 P M T O M I D N I G H T H I LT O N B A LT I M O R E , I N N E R H A R B O R • C O C K TA I L S , D I N N E R , D A N C I N G , B L A C K T I E It’s the 50th year that this community has stepped forward

✦ PLATINUM – IFF

and asked, “Can we help?” And oh you have. Year after year,

GOLD – BB&T • Comcast • Creston G. & Betty Jane Tate Foundation •

you’ve been there when you were needed. The highlight of

Mark & Lynne Powell, The Powell Foundation • What’s Up? Media • WRNR 103.1FM

your giving has always been the Anne Arundel Medical Center

SILVER – AAMC Medical Staff • Alacrity Collections Corporation •

Foundation’s Annual Gala. Since that first black tie was tied,

Hargrove • Hyatt Weber • Johns Hopkins Medicine • M&T Bank • RxNT • Severn Savings Bank • Zachary's

that first black dress stepped onto the dance floor, and that first

BRONZE – Aerotek • Anesthesia Company, LLC • Carol M. Jacobsohn

generous donation was given, you’ve been there for us. Again

Foundation • Chesapeake Eye Care & Laser Center • Drs. Walzer, Sullivan, Hlousek & Jones • Heim Lantz CPA's Advisors • Kaiser Permanente

this year, we need your generosity and support for the Anne

MEDIA – Capital Gazette Communications • Chesapeake Physician •

Arundel Medical Center’s cardiovascular program.

Eye on Annapolis • Liquified Creative • Severna Park Voice • Weitzman Agency • 1430 WNAV

Purchase your tickets today at:

aamcgala.org

For more information about the 2016 Heart of Gold Gala, contact Kendra Smith Houghton at 443-481-4739 or khoughton@aahs.org

SOLUTIONS

Using Evidence-Based Healthcare Design To Make Buildings Work for Patients B Y FA I T H N E V I N S H AW K S

PHOTOGRAPY BY MARKS, THOMAS ARCHITECTS

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s healthcare providers become more focused on understanding and meeting patient needs, they must design facilities that help staff do their work and that help patients heal into greater account. In a society where scientific data is more readily accepted than aesthetics, and issues of social responsibility are now in the forefront, evidence-based design may be today’s answer to successful design solutions. Architects and engineers are familiar with basing design decisions on empirical scientific research for energy efficient buildings, code-related requirements and structural performance, but can a scientific approach improve patient care?

As Michael Kimmelman, New York Times design critic, says in a recent article, “Can socially concerned design also be Architecture with a capital A? In many ways, this is the central argument in architecture today, with a new generation more attuned to issues of social responsibility and public welfare. The discussion has posed a larger, fundamental question about the role of architects, and to what extent they can or should be held responsible for how buildings work.”

The Origin of Evidence-Based Design Evidence-based medical practice began in the 1970s, but it wasn’t until 2006 that evidence-based design (EBD) was introduced to facility guidelines. The Center for Health Design defines EBD as the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. In 2009, EDAC, a program accrediting and certifying architects in evidence-based design, was launched. Since that time, approximately 1,200 environmental studies have been conducted. There is now a large

and growing body of evidence attesting to the impact of healthcare environments on patient stress, patient and staff safety, staff effectiveness, and the quality of care.

The First Step: Design Research The first step of EBD is design research, which explores the relationships between the physical environment and behavioral, physical and psychological responses. Exam room design has not changed significantly in the past 25 years, while the way in which medical services are provided has changed enormously.

Chase Brexton Health Service’s clinic is an example of how design research can be used to improve the patient experience.

After conducting a series of detailed discussions about how, what and where clinical services were being provided in the clinic’s previous design environment, the architectural team designed an exam room that can maintain client privacy, provide interaction between various medical service providers and save time and resources.

Each exam room has a separate entry for the patient and the physician. A patient accessible hallway runs along a series of exam rooms with sliding entry doors, so they don’t interfere with the hallway access. The line of exam rooms flank a communal work area where medical service providers work together in an open office arrangement with available quiet rooms nearby. This design allows patients to remain in one exam room while receiving care from a variety of providers as appropriate for their medical issues. As a result, various medical disciplines can work together more freely and the patient does not have to risk being lost or disoriented trying to find the next service space.

Lean Building Design Principles “Lean” principles were used throughout the Chase Brexton design process. The Lean process became well known for its implementation in the Japanese car industry, specifically Toyota. According to the Lean Enterprise Institute, the five-step process that guides the implementation of lean techniques is: 1. Specify value from the standpoint of the end customer by product family.

2. Identify all the steps in the value stream for each product family, eliminating whenever possible those steps that do not create value.

3. Make the value-creating steps occur in tight sequence, so the product will flow smoothly toward the customer.

4. As flow is introduced, let customers pull value from the next upstream activity.

5. As value is specified, value streams are identified, wasted steps are removed, and flow and pull are introduced. Repeat the process until a state of perfection is reached in which perfect value is created with no waste.

Using this repetitive linear process, a rigorous design approach was employed for Chase Brexton’s state-of-the-art outpatient community clinic. As a result, the clinic saved not only time and resources, but also reaped significant improvements in safety, quality, patient satisfaction, and health.

Better Access and More Research Fosters EBD A growing body of research is now available, including current neuroscience studies that are determining how hospital patient rooms affect brain physiology. For professionals to access this data, many trade

organizations have established centers for information, such as the International Interior Design Association (IIDA) Knowledge Center and the American Institute of Architects (AIA) Soloso.

Soloso was launched in 2007 as a website that offered a repository of architectural trends, solutions, products, and strategies, as well as a database of articles on different project types. With designer software increasingly able to integrate building modeling information, architects now have more tools than ever before to use an inclusive design process that integrates client knowledge, occupant needs and researched outcomes.

It’s clear that evidence-based design has been used by architects ever since architecture became a profession. Using historic precedents, client interviews, postoccupancy evaluation, and more, architects have long been making design assertions with facts that support them. The future of EBD lies in the quantity, type and access of research that can inform the design process.

Combined with using Lean processes as a research and implementation tool, physical environments for healthcare can become more sensitive to the needs of patients and providers.

The challenge for architects and designers is to use the most current research to inform their design while maintaining their creativity and their sensitivity to the unique needs of the healthcare environment they’re designing. CP

Faith Nevins Hawks, AIA, LEED AP, Marks,Thomas Architects, can be reached at faithn@marks-thomas.com.

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Jennifer McQuade, MD, FACS, FASCRS, colorectal surgeon at Virginia Hospital Center Physician Group

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Advancing Digestive Disease

Detection and Care Treating Rectal Cancer, Ulcerative Colitis and Food Allergies The Western lifestyle has contributed to a high incidence of digestive tract diseases. Our medical specialists discuss the latest approaches in treating three common digestive conditions – ulcerative colitis, food allergies and rectal cancer.

BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN AND KEITH WELLER

Successful Treatment of Ulcerative Colitis

As the incidence of ulcerative colitis skyrockets in developing countries like China and India, where residents increasingly consume highly processed, high-fat and high-sugar foods, the role of diet in causing this disease would seem clear. Yet, like many immune diseases, a combination of genetics and environmental factors appear to be required. Witness the fact that only 35 percent of both identical twins have the disease.

“Patients always ask, ‘how did I get this?’” says Alyssa Parian, MD, assistant professor of medicine, Johns Hopkins Bayview Medical Center.“I explain that there isn’t a clear-cut cause. Variations in over 100 genes have been identified as contributing to ulcerative colitis risk.

Less-diverse microbiomes definitely play a role in the disease. There may be a viral trigger. Using antibiotics at less than one year of age and low adolescent exercise levels may increase the risk, but some patients have always been healthy and active. Breastfeeding and vaginal delivery seem to be protective.”

ULCERATIVE COLITIS DIAGNOSIS

“Ulcerative colitis sufferers are usually young people who look well and have no other medical conditions,” explains Dr. Parian.“It is common to be initially misdiagnosed with irritable bowel syndrome or hemorrhoids.

Their bloodwork including hemoglobin may be normal, but they may have low iron levels. Checking serum inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein can help determine if something more serious is going on. Concomitant liver disease is not uncommon and liver function tests should also be checked.”

After taking a history and physical in patients presenting with bloody diarrhea or other symptoms, physicians may order serologic markers, a CBC, a comprehensive metabolic panel, inflammation markers, and stool assays to rule out infections. A Prometheus Panel, while only 60 percent accurate and expensive, may be warranted in some patients to differentiate between ulcerative colitis and Crohn’s disease.

The next step is a colonoscopy.“Colonoscopy and biopsies are important tests to definitively make the diagnosis of ulcerative colitis. We may also do a small bowel series or MRI to rule out Crohn’s disease,” Dr. Parian states.

ULCERATIVE COLITIS TREATMENTS

For mild to moderate colitis, mesalamines such as Lialda® or Pentasa® are oral pills with minimal side effects that heal the top layer of the colon.“The only, extremely rare, issue with these medications is kidney function,” Dr. Parian explains.“I usually prescribe them for at least one year. Patients should get their kidney

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Patients should be referred to a colitis specialist for further management if they can’t get off steroids.

The risk of colorectal cancer rises substantially after eight years of ulcerative colitis, with a higher risk in patients with active inflammation.

– A LY S S A PA R I A N , M D

FECAL TRANSPLANTS SHOW PROMISE

Fecal transplants, shown to be effective in treating C-difficile (see article in September/October 2013

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Chesapeake Physician), are under consideration as a treatment for IBD. Dr. Parian explains, “Two 2015 studies reported in the Gastroenterology Journal looked at fecal transplants. The first, which used an enema as the method of transplant, resulted in 24 percent of patients in remission versus 5 percent of those on placebo. Those who responded had a microbiome that became more diverse. This approach is best for those with a shorter and milder disease history. The fecal transplant is safe short-term, and the only side effects are bloating and gas, but long-term adverse events are not yet known.

Interestingly, patients are very open to trying it.”

APPROPRIATE MANAGEMENT

“The biggest issue is that long-term prednisone use is not appropriate,” Dr. Parian remarks.“One of the quality measures for inflammatory bowel disease assesses how long your patients have been on steroids and what your plan is. Patients should be referred to a colitis specialist for further management if they can’t get off steroids. The risk of colorectal cancer rises substantially after eight years of ulcerative colitis, with a higher risk in patients with active inflammation.”

Better Rectal Cancer Surgery and Enhanced Recovery With about 50,000 deaths in 2015 from colorectal cancer and 39,000 new cases of rectal cancer each year, ensuring the efficacy of treatment protocols is imperative. Jennifer A. McQuade, MD, FACS, FASCRS, colorectal surgeon, Virginia Hospital Center Physician Group, remarks,“We talk a lot about breast cancer, but one in 20 (five percent) of Americans risk getting colorectal cancer. Thankfully, death rates are declining due to more screening and better treatments.”

She explains,“While many patients have no symptoms, the two biggest symptoms are rectal bleeding and a change in bowel habits, such as more frequent, looser, bloody, or narrower stools. Unexplained weight loss and fatigue should also be investigated.

“I tell patients, ‘Never assume rectal bleeding is normal, or that it’s hemorrhoids.‘ If patients have rectal bleeding or a change in bowel habits, they should see their primary care physician, who may order bloodwork, a colonoscopy and

PHOTO BY KEITH WELLER

function checked at one week and then at least yearly. If patients are completely healed, they can trail off it, but only a very small percent never need medications again.”

Progress can be measured through a fecal calprotectin assay – a newer, more sensitive stool test that measures levels of inflammation in the colon. Its sensitivity and specificity for diagnosing inflammatory bowel disease was found by a recent study to be 82 to 89 percent.

Dr. Parian states, “In a more acute setting, prednisone is excellent for short-term use to induce remission. Then mesalamines can be used after prednisone has the disease under control. Azathioprine, an immunosuppressant often used in kidney transplants, can be useful if patients cannot taper off prednisone or are not responding to it. This oral pill, which requires more frequent bloodwork because it can cause cytopenia, is not a good choice for noncompliant patients.”

She continues,“Remicade® (infliximab) is the best therapy for severe ulcerative colitis in patients who are steroid refractory or dependent. While it suppresses the immune system and increases the risk of infections such as TB, I personally haven’t had any patients with serious side effects or infections.”

The newest medication is Entyvio®, (vedolizumab), an alpha4beta7 integrin antibody that acts on a different target than Remicade. It specifically targets the GI tract and doesn’t have any known risks for infections or malignancy and therefore is a good first line treatment for elderly patients and those with a history of cancer.

“Entyvio, which entails a half-hour infusion every other month after three initial infusions, only acts on the GI tract, stopping inflammation before it starts,” explains Dr. Parian.

“The data on this drug for ulcerative colitis is very good. It also has minimal side effects, but it’s more expensive and not yet always covered by insurance.”

Even with newer medications, the percent of patients needing colorectal surgery hasn’t decreased significantly; roughly 50 percent of those with severe colitis still require surgical intervention.

Alyssa Parian, MD, assistant professor of medicine, Johns Hopkins Bayview Medical Center

Removing the entire mesorectum, the fatty tissue containing blood vessels and lymph nodes adjacent to the rectum, called Total Mesorectal Excision(TME), has lowered the recurrence rates in rectal cancer. Dr. McQuade explains,“The blunt manual dissections performed in the 1990s could leave cancer cells behind. A Lancet article in 1993 found that TME had a recurrence rate of only five percent compared with 13 to 25 percent for conventional surgery. Today, TME is the standard of care.”

The OSTRiCh Consortium (Optimizing the Surgical Treatment of Rectal Cancer) was founded in 2011 to improve rectal cancer care in the US. Its five core principals include using: 1. TME 2. Specific techniques for pathology, including reporting the distal and circumferential margins, lymph nodes, genetics and how intact the mesorectum is 3. Specific imaging techniques (e.g., CT, MRI, transrectal ultrasound) to identify patients at high risk of local recurrence 4. Newer neo-adjuvant and adjuvant therapies including radiotherapy and chemotherapy 5. A multi-disciplinary team approach personalized to each patient’s needs

possibly a CT scan. Colonoscopy is good but there’s a ‘miss’ rate for polyps. Depending on your personal history and symptoms, a repeat colonoscopy may be indicated.”

Some 90 percent of those with rectal cancer are age 50 or older with a median age of diagnosis of 69 years old. Obesity, family history and inflammatory bowel disease increase the risk of rectal cancer but it can be viewed as an ‘equal opportunity killer,’ in that men and women and most ethnic groups have similar risks.

RECTAL CANCER TREATMENTS

The treatment for rectal cancer is primarily surgical, with adjuvant therapy depending on the stage. Dr. McQuade comments,“Colon and rectal cancers are often lumped together, but they’re managed differently. It’s difficult to operate in the non-compliant bony pelvis. How close the cancer is to the sphincter mechanism dictates our ability to perform sphincter preservation surgery and avoid colostomy.”

“The idea of this consortium is similar to the Center of Excellence concept, but national in scope,” explains Dr. McQuade.“My protocol is that all patients have a thorough physical exam, including a DRE, a CBC and CEA, a CT scan of the chest, abdomen and pelvis and specifically for rectal cancer. A rectal MRI is essential to delineate the tumor and nodal staging of rectal cancer and assess circumferential radial margin positivity which can alter our treatment protocol.”

In Stage 3 rectal cancer, the current standard of care is neo-adjuvent chemotherapy and radiation, surgery, and postoperative chemotherapy. Dr. McQuade states,“There are three surgical options: traditional open, laparoscopic and robotic surgery. Selection depends on the patient’s body habitus, previous surgical history, size and location of the tumor, and patient preference. For the vast majority of patients, I try minimally invasive surgery first; if we can’t proceed safely, we convert to open.”

ENHANCED RECOVERY

Enhanced recovery, or fast-track, programs use evidencebased protocols to improve outcomes and lower costs by

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Physicians should not give in to patients’ requests for broad screening. A more appropriate approach is to refer patients to a specialist to discuss their specific issues. – M O N I K A K O R F F, M D decreasing the physiological stress associated with surgery.

“We’ve been using enhanced recovery protocols for years but over the last 18 months we have made even further improvements. By managing peri-operative care, we can help patients through the stress of surgery, decrease length of stay and complications, and promote an earlier return of bowel function,” Dr. McQuade says. “Catheters are removed sooner, patients begin walking the day of surgery, they receive a liquid diet the night of their surgery, and nasogastric tubes are no longer used.” Changes in anesthesia also help patients recover faster. All of these measures combined allow patients to return home two to four days after surgery.

Fighting Food Allergies

Another price that citizens in the US and other industrialized countries pay for their lifestyle is food allergies. These affect an estimated four to six percent of people – by some estimates, perhaps as high as 10 to 12 percent of children – and increasing by 50 percent since 2007. Peanut allergies, the most serious and typically lifelong allergies, have doubled in the past 10 years.

According to the CDC, eight major foods account for 90 percent of allergies: cow’s milk, eggs, wheat, soy, peanuts, shellfish, fish and tree nuts. Of these, cow’s milk, egg and soy allergies typically begin in childhood and are outgrown by age 16, although a recent Johns Hopkins School of Medicine study found that children are taking longer to outgrow milk and egg allergies.

Shellfish, the principal allergen in adults, can develop at any point in life.

FOOD ALLERGIES VS. SENSITIVITIES Monika Korff, MD, a specialist in allergy and immunology, Allergy & Asthma Center of Central Maryland

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Monika Korff, MD, a specialist in allergy and immunology with the Allergy & Asthma Center of Central Maryland, distinguishes between a food allergy and sensitivity.“The strict definition of a food allergy is one that is triggered by IgE antibodies to specific food proteins or that causes adverse and potentially life-threatening reactions, whereas a sensitivity is less serious but harder to assess. A positive skin test or blood test without a patient reaction does not meet the definition of a food allergy.”

Indications of food allergies range from

gastrointestinal symptoms to skin conditions such as hives or rashes, to respiratory or cardiovascular symptoms. They also may cause tingling of the mouth or tongue.

FACTORS CONTRIBUTING TO FOOD ALLERGIES

The findings of a Johns Hopkins Bloomberg School of Public Health study published online Feb. 24, 2015 in Nature Communication by Xiaobin Wang et al. analyzed thousands of DNA samples from young children with peanut allergies and their parents. This study suggested that the HLA-DR and -DQ gene region on chromosome six probably poses significant genetic risk, as it accounted for about 20 percent of peanut allergy in the study population.

Those at risk likely then require DNA methylation via environmental exposures to develop the allergy.

Some proteins contained in shellfish are also found in dust mites. According to Dr. Korff,“Food protein dust is contained in every household. When you’re at risk and you get early exposure through broken skin, such as in eczema, rather than through the gut, you’re likely to get an allergic reaction rather than tolerance.”

She adds,“There’s a complex interaction between the immune system and the environment. The latter has changed so much since our parents’ generation. The food industry has changed to include GMOs and far more processed foods. Factors such as a virus or stress may cause the second ‘hit’ or trigger needed to turn those with a specific HLA type into people with food allergies.”

Non-IgE mediated and non-anaphylactic sensitivities are increasing. Dr. Korff says,“The gluten protein in wheat has achieved notoriety as the alleged cause of many food allergies or sensitivities, resulting in a new diagnostic code for non-celiac gluten sensitivity. Gluten has a proven inflammatory effect on the body. Some patients with diseases such as rheumatoid arthritis get better when they avoid gluten. Milk proteins also can increase inflammation. We may recommend avoiding both milk and gluten proteins for eight to 12 weeks, then reintroducing one at a time to determine the patient’s reaction. We’re guided by the patient’s response.

“There certainly are hormonal influences,” Dr. Korff grants.“Pregnancy and menopause can either increase or decrease the severity. Some of my patients with inhalant allergies and asthma wish they could be pregnant forever.”

EARLY EXPOSURE MAY BE PROTECTIVE

Dr. Korff states,“We don’t know definitely what causes food allergies, but there is increasing evidence that early exposure to pathogens, as long as exposure is not through the skin, is protective. Many studies are looking at the rates of allergies in those born through C-section versus vaginal births. Colonization of gut bacteria also seems to be important.”

A randomized study by George Du Toit et al. reported in the New England Journal of Medicine in March 2015

found that infants with a pre-existing sensitivity to peanut extract had fewer allergies when exposed to peanuts than when they avoided exposure.

DIAGNOSING AND MANAGING FOOD SENSITIVITIES/ALLERGIES

“Diagnosing and managing food sensitivities can be frustrating for physicians and patients alike,” acknowledges Dr. Korff.“Unfortunately, much of the burden lands on the patient.”

While skin tests are typically the first diagnostic tool employed, an immunoassay blood test may be needed when patients have severe skin conditions or poorly controlled asthma, are taking antihistamines, steroids or other medications that interfere with results, or are at risk for anaphylaxis.

Dr. Korff advises physicians to avoid testing patients globally for food allergies.“Physicians should not give in to patients’ request for broad screening. A more appropriate approach is to refer patients to a specialist to discuss their specific issues. Food allergies aren’t hidden.

You know if you have it.”

She adds,“A widespread/scattershot screening approach frequently results in a non-clinically significant result in which a patient has a positive test for an allergen but has no clinical reaction to that food, which can range from itchy or tingling lips to anaphylaxis.”

Dr. Korff notes that it takes about eight weeks of food avoidance to get a clear picture of a food allergy or sensitivity.“Getting the right diagnosis can decrease stress and unnecessary medication. The term food allergy is broad and perhaps misused. It’s important to listen to the patient carefully and refer to a specialist early to determine if it’s a food allergy or sensitivity.”

Physicians should refer high-risk children to a specialist early on, especially if they have atopic dermatitis.

“Eczema that develops early in life should be managed by a pediatrician with an allergist consult,” states Dr. Korff.

TREATMENT

“We don’t have a treatment for food allergies; we have to treat the symptoms through avoidance and interventions such as inhalers, antihistamines and epinephrine injectors,” Dr. Korff notes.

Dr. Korff’s key recommendation to other physicians is to create a plan for patients with suspected allergies.

“Studies have shown that close to 60 percent of patients walk out of the emergency department or primary care physician’s office without a plan. Epinephrine injectors are a proven life-saving treatment, and food-related deaths are almost always traced to not having one, or to delayed administration.”

She also hopes to dispel the myth that shellfish allergies are related to iodine.“Patients are unnecessarily warned not to get IV contrast. It’s a food protein allergy that has nothing to do with iodine.” CP

Alyssa Parian, MD, assistant professor of medicine, Johns Hopkins Bayview Medical Center Jennifer A. McQuade, MD, FACS, FASCRS, colorectal surgeon, Virginia Hospital Center Physician Group, Arlington, Va. Monika Korff, MD, a specialist in allergy and immunology with the Allergy & Asthma Center of Central Maryland

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Helping Patients

BREATHE Learn about the latest diagnostic and treatment approaches for two common conditions that affect your patientsâ&#x20AC;&#x2122; ability to breathe - chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA).

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EASIER Advances in Treating COPD Smoking is a risk factor for a vast array of diseases, but perhaps never more so than for COPD. An umbrella term for chronic bronchitis and emphysema, COPD often has few or no symptoms until advanced, but it should be suspected in those with shortness of breath or a chronic cough. In emphysema, the gradual destruction of the alveoli, accompanied by the loss of elastic recoil, causes airways to close during exhalation while flattening the diaphragm, whereas chronic bronchitis entails inflammation of lung passageways.

DIAGNOSING COPD

Edward Schaefer, MD, a board-certified physician in internal medicine, pulmonary disease and sleep medicine and member of the Howard County Center for Lung and Sleep Medicine, says, “One of the challenges in diagnosing COPD is that even many long-term smokers have insignificant clinical symptoms. These patients should get a breathing test and early intervention.

Any patient that smokes who is coughing or wheezing should be tested.”

BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN

In addition to pulmonary function tests, other commonly ordered tests are arterial blood gas analysis, chest X-ray and/or chest CT. Individuals with COPD often have abnormal pulmonary function test results, but to rule out asthma, a lung diffusion capacity (DLCO) test may be ordered. Considered among the more convenient yet clinically valuable tests for lung function, it measures the transfer of gas upon inhalation to the pulmonary capillaries.

SMOKING CESSATION IS KEY

“Smoking cessation is really primary in treating those with COPD,” advises Dr. Schaefer.“A variety of options exist, including free programs from area health departments, 1-800-Quit-Now, nicotine replacement gum, patches, and Chantix (varenicline).”

While a February 2015 study in the Journal of the American Medical Association found that varenicline was more effective than a placebo in helping smokers quit, the FDA has retained its blackbox warning over concerns about potential side effects such as seizures, aggression while drinking, and cardiovascular events.

Physicians have new ammunition to advise patients against

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using e-cigarettes to help them quit. A meta analysis published online in January 2016 in The Lancet Respiratory Medicine by Sara Kalkhoran, MD, systematically reviewed the findings of 20 studies with control groups, out of 577 total studies identified. The analysis found that e-cigarette usage lowered the likelihood of quitting smoking by 28 percent.

SYMPTOM RELIEF IN COPD

“Treatment for those with COPD is largely aimed at making people feel better and treating their airway obstructions,” says Dr. Schaefer. Treatments are evolving to provide more convenient, long-lasting delivery mechanisms and a combination of medications. Spiriva® (tiotropium), an anticholinergic first approved in 2004 as a capsule, now is available as an inhalation mist (Spiriva Respimat) and powder (Spiriva HandiHaler). STIOLTO™ RESPIMAT®, available since the summer of 2015, combines tiotropium with a long-acting beta2-adrenergic agonist, olodaterol.

Dr. Schaefer comments,“Tudorza™ Pressair™, a new long-acting anticholinergic similar to Spiriva, has been shown to increase breathing and decrease the incidence of exacerbations, which cause more lung damage. Another newer treatment, BREO Ellipta, similar to Advair, only needs to be taken once a day.

“Patients admitted for an exacerbation of their COPD have been shown to have an increased risk of future admissions,” he adds.“Payers are beginning to incentivize us to keep people healthier and out of the hospital. While we don’t have all of the answers, patients should stop smoking, be seen within two weeks of discharge and determine appropriate therapy while in the hospital – oxygen therapy or newer, longer-acting therapies such as Daliresp® (roflumilast), which reduces inflammation in the lungs.”

PULMONARY REHAB

He continues,“Remaining active is also important, and enrolling patients in a pulmonary rehab program improves function. In addition to getting supervised exercise three times per week, the educational component of rehab is important. Billions are spent on the new inhalers, but patients still need to know how to use them properly. In rehab programs, patients are observed, monitored and pushed to their limits, so they don’t just go home and sit around. Most people who complete the eight- to 10-week program can do more, such as singing in the choir or walking farther even if their lung function doesn’t increase.”

Patients with COPD may also benefit from a cardiovascular consult and consideration of the possibility of other lung diseases that may impair function, including cancer.

OXYGEN THERAPY IN COPD

Oxygen can decrease the strain on heart muscles, reduce shortness of breath, and improve cognition and function.

Studies have found that patients live longer when they used oxygen at least 15 hours a day.

Many patients mistakenly think that insurance will pay for oxygen therapy if they have shortness of breath, but they should be informed that they must demonstrate oxygen saturation levels less than or equal to 88 percent to qualify.

Oxygen concentrators are newer, more portable electric devices that separate the oxygen out of the surrounding air.

“Staying mobile is easier with today’s oxygen concentrator devices, which are about the size of a woman’s pocketbook,” Dr. Schaefer explains.“Battery driven devices can be plugged into a car and are also airplane friendly.”

SEVERE COPD: LUNG VOLUME REDUCTION SURGERY

“Lung volume reduction surgery (LVRS), a procedure in which 20 to 30 percent of damaged lung tissue is removed, is a less popular procedure than it used to be due to high surgical morbidity and initially high mortality rates,” Dr. Schaefer explains. Comorbid conditions may also prevent many patients from undergoing this procedure. According to the National Emphysema Treatment Trial (NETT)’s results, LVRS is likely to be beneficial for patients with heterogenous upper-lobe disease combined with low exercise capacity.

Patients with poorly controlled COPD may soon be able to take advantage of newer non-invasive approaches. An alternative under investigation is bronchoscopic lungvolume reduction that places endobronchial valves in the airways to the most emphysematous portion of the lung.

These self-expanding, one-way valves prevent air from entering the diseased lobe, where it becomes trapped, and divert it to less-diseased portions of the lung.

Dr. Schaefer says,“This procedure seeks to achieve the same goal as the LVRS procedure by inserting a one-way valve that solves the problem of air being trapped and not exchanged. It keeps the airways open and prevents damage to healthy lung tissue.”

A study by Davey et al. published in The Lancet in September 2015 found that, in appropriate patients, endobronchial valve placement results in improvements

Patients admitted for an exacerbation of their COPD have been shown to have an increased risk of future admissions.

– E D WA R D S C H A E F E R , M D

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CPAP works 95 times out of 100 if it’s used properly.

Education is key.

– KONRAD BAKKER, MD

Konrad Bakker, MD, owner of Comprehensive Neurology and Sleep Medicine, is board certified in clinical neurophysiology, neurology and sleep medicine.

in lung function comparable to those seen with LVRS. Patients in this randomized, double-blind, controlled study demonstrated improved exercise capacity.

“Several companies are trying to get their devices approved, but none have succeeded yet,” Dr. Schaefer concludes.

The Dangers of Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is estimated to affect some 22 million Americans, causing sleep fragmentation and/or oxygen desaturation. Konrad Bakker, MD, a physician boardcertified in clinical neurophysiology, neurology and sleep medicine, and owner of Comprehensive Neurology and Sleep Medicine in Frederick and Rockville, Md., notes that OSA is somewhat of a misnomer.“It’s typically caused by how the

airway relaxes during sleep and is not an obstruction per se.”

“OSA was originally described in the early 1980s as something to be concerned about, but it wasn’t taken seriously until the 1990s,” states Dr. Bakker.

OSA COMORBIDITIES

Untreated OSA has been closely linked with a number of cardiovascular diseases, including hypertension, coronary artery disease, stroke, and pulmonary hypertension.

Dr. Bakker explains,“Some 50 percent of those with atrial fibrillation, and the same percentage of diabetics have OSA. Thirty percent of those with this condition have high blood pressure. OSA predisposes people to these diseases as well as to car accidents. As a result, DOT physicals now require that patients with OSA be on and compliant with CPAP.

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SURVEY DETECTION OF OSA

Two simple, self-administered, validated surveys can identify those at high risk for OSA, and rule out those who snore but have a low risk. The Berlin Questionnaire was developed in 1998 at a medical conference in Berlin, Germany, by a group of family practice physicians and sleep researchers. It assesses snoring behavior, daytime sleepiness and a history of hypertension and obesity.

A second survey, STOP-BANG, is an acronym for the risk factors it measures: loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (Bang). It has been validated at greater than 80 percent reliability. Scores of ≥3 detect moderate-to-severe OSA, and severe OSA with a sensitivity of 93 and 100 percent respectively.

APAPS ARE GAME CHANGERS FOR SLEEP STUDIES

A drop of 10 to 15 percent in weight has been shown to cut apnea in half, but only one in 20 people manage to lose weight.

Most people turn to a device for help. Continuous positive air pressure machines (CPAP) have been commercially available since the mid 1980s. “CPAP works 95 times out of 100 if it’s used properly,” explains Dr. Bakker. “Education is key; compliance is less than 50 percent if patients aren’t educated, but 80 percent if they are.”

He adds,“Monitoring CPAP compliance has gotten easier with

the development of a chip that tracks its usage. Today, you can follow its usage online and determine if the patient has apnea events.”

Auto Adjusting CPAP machines (APAPs) utilize a sensitive algorithm technology that allows the machine to detect how much inhalation pressure is required for each breath, within a customized range. APAPs typically contain software that allows patients and their physicians to adjust and monitor their therapy. The patient’s compliance and therapeutic efficacy can be monitored over a 30-day period, rather than a single night.

Insurance companies have driven the demand for home sleep studies, which has caused the use of sleep labs to plummet. Dr. Bakker explains,“Many insurers now require home sleep studies followed by APAP titrations for 30 days at home. You need preauthorization for a sleep lab study, which is hard to obtain. OSA would be perfect for a disease management program approach, but the insurance companies have tended instead to deny care.”

Randomized controlled trials have shown that APAPs can reduce the apnea-hypopnea index to less than 10 events/hour in 80 to 95 percent of patients.

ORAL AIRWAY DILATORS AND PILLAR

For those with less severe sleep apnea, dental appliances may be sufficient. Costing around $2,500, they have been shown to decrease OSA by 50 percent, comparable to the effects of losing

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20 to 40 pounds. Oral airway dilators, which push the tongue and jaw forward to enlarge the airway and improve airflow, are among the most popular.“Most insurances will pay for this device when pre-authorized by a physician, though finding a dentist who offers them can be challenging,” observes Dr. Bakker. Ironically, however, dental colleges do not offer residencies for OSA. SURGICAL TREATMENTS FOR OSA

“Dr. Bakker states,“Uvulopalatopharyngoplasty and other older surgeries were like a tummy tuck for the back of the throat.

Used for the past quarter century, this procedure removes excess tissue from the soft palate and pharynx, as well as the tonsils, where indicated.”

Inspire® therapy is a newer, expensive approach that can cost $30,000.“Inspire therapy is FDA-approved but no insurer pays for it yet,” Dr. Bakker notes. Implanted during an outpatient procedure, Inspire uses a breathing sensor and a stimulation lead, powered by a small battery, to continuously monitor breathing during sleep. It delivers mild stimulation to key airway muscles, and moves the tongue and other soft tissues out of the airway to facilitate breathing.

In 2010, the Stimulation Therapy for Apnea Reduction (STAR) clinical trial was undertaken to measure Inspire therapy outcomes after one and three years. The one-year outcomes, published January 2014 in the New England Journal of Medicine, demonstrated

a 78 percent reduction in apnea-hypopnea events and an 80 percent decrease in oxygen desaturation from baseline. Snoring reported by the person’s bed partner decreased from 80 to 17 percent.

ADAPTIVE SERVO VENTILATION

Those with rarer sleep apnea conditions may benefit from Adaptive Servo Ventilation (ASV) to provide positive airway pressure ventilatory support. ASV uses an algorithm to adjust the pressure so that it can stabilize breathing patterns and arterial blood gases. That in turn reduces the number of nighttime awakenings and discomfort.

“It works well for those with central or complex sleep apnea,” says Dr. Bakker.“However, when one study found that those with an ejection fraction of less than 40 percent had higher mortality rates, a warning was issued to everyone using these devices.

Instead of getting more data, we jumped to being overly cautious.

My feeling is that ASV will work for those with congestive heart failure.” CP Edward Schaefer, MD, board-certified in internal medicine, pulmonary disease and sleep medicine, is a member of the Howard County Center for Lung and Sleep Medicine in Columbia, Md. Konrad Bakker, MD, board-certified in clinical neurophysiology, neurology and sleep medicine, is the owner of Comprehensive Neurology and Sleep Medicine in Frederick and Rockville, Md.

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POLICY

A Champion for a HEALTHIER

Q

In addition to spending

three to four days per week practicing pediatric neurology, and serving as the medical director of Edmarc Hospice for Children, Virginia Lieutenant Governor Ralph Northam has pushed an ambitious healthcare

A

agenda, as he describes in this interview.

Q: How did you pick pediatric neurology?

My grandfather was a thoracic surgeon and my mother was a registered nurse.

I had hoped to fly for the Navy but I couldn’t pass the vision test. I started to think about being a doctor. At first I wanted to be a surgeon like my grandfather, but when I did my surgical rotation, it was very competitive. I started to think that I had always liked children. I worked in pediatrics for the remaining two weeks of my rotation. I liked the people there and went on to do my pediatric training. During my first year of peds, I got a bit tired of checking children’s ears, so I did a pediatric neurology fellowship at Walter Reed. I was at Hopkins for six months. It’s a fascinating field and getting more interesting every day.

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VIRGINIA

An Interview With Virginia Lieutenant Governor Ralph Northam, MD

BY JACQUIE COHEN ROTH AND LINDA HARDER P H O T O G R A P H Y B Y J AY PA U L

Q: How did you get interested in politics?

In 2006, I told my Pediatrics chairman that I was frustrated with insurance authorization and I started to think about what I could do to make a difference, and thought about running for office.

I went home and talked to my wife and she looked at me like I was crazy. So in 2007, I ran for the 6th state senate district, including the Eastern Shore and about half of Norfolk. The district wraps around the Chesapeake Bay, which is where I grew up; the demise of the Bay was another incentive to run.

I was totally naïve in politics, but I beat an eight-year incumbent. One advantage I had was that I had roots in the Eastern Shore. I ran again for re-election in 2011, and in 2013, they approached me

about running for lieutenant governor, as someone with a rural background and who understood healthcare. Governor McAuliffe, who was a persistent person, asked me in what I guess was a weak moment. I ran for LG in 2013 and was successful.

So here we are.

Q: Aren’t you still practicing medicine?

The lieutenant governor position is part time, so I still see patients three-and-ahalf to four days a week. The Governor’s philosophy is that you sleep when you’re dead.

Q: What have been some of your healthcare initiatives over the years?

I introduced the smoking ban in restaurants in 2008 and Governor Kaine

signed that into law. Then I did a lot of work in childhood obesity, including a bill to mandate 30 minutes of exercise per day through middle school, but Governor McDonnell vetoed the bill in 2010 because he said it would cost money to build more gymnasiums. That legislation is probably going to be passed this year.

Then I introduced legislation for concussions that educated student athletes, their families, coaches, and trainers. If an athlete is suspected of having a concussion, he or she would be removed from play and cleared by a provider before they could return. The thing we really worry about is second impact. Despite better equipment and monitoring, our athletes are faster and stronger, with increased acceleration/ deceleration, and the brain is not designed to handle that.

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From a business perspective, every day that we don’t expand Medicaid, we’re literally handing about $5 million to our neighboring states.

– L I E U T E N A N T G O V E R N O R R A L P H N O RT H A M , M D

Q: Describe your efforts to improve mental health treatment.

Now, at the LG level, one area I’m focused on is mental health. We don’t have to look far to find someone who’s affected by mental illness. That initiative was started in 2007 or 2008 when the Virginia Tech tragedy occurred. In the fall of 2013, Senator Deeds’ son, who had some mental health issues, took his own life and that put things back on the radar screen.

Then Governor McDonnell formed the Mental Health Task Force. When Governor McAuliffe took over, we continued the Task Force, and I became the chair of that. We’ve given the Governor about 26 recommendations, including crisis intervention for those who need acute care, ongoing therapy, law enforcement because there are too many with mental health issues in our jails, and telehealth.

In Danville, in southern Virginia, for example, we have a very good community service board that takes care of those with mental illnesses. But there are no psychiatrists. We used telehealth to connect them with psychiatrists at the University of Virginia. The doctor can write a prescription and they can walk down the hall to get it filled.

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Q: Another area of interest is children’s health. What initiatives have you undertaken for children?

The Governor’s major focus is economic development, and he’s given me freedom to do what I want as long as it contributes to that. We formed the Children’s Cabinet, which is the first time a governor has ever formed this, and then within the cabinet is the Commonwealth Cabinet for Childhood Success, and I chair that. Our main focus is pre-K education, and we were awarded a grant for $70 million over four years to expand access to 13,000 kids.

We’re doing a lot of work with quality, accessible and affordable childcare, since most parents are working. We also want to make sure that our children are prepared to go to school, that their health is good, that they have good nutrition, that their immunizations are up to date, and so on.

This year’s budget includes home visits for at-risk families, so the mother has an avenue to further her education and we help to take care of her children.

We’re also working with long-acting reversible contraceptives (LARCs) so that women can decide if and when they want to get pregnant, and to help with spacing children, especially for single mothers.

Education and access to healthcare is key. What I try to emphasize to folks is that we would all like to see the number of abortions declining. Let’s all agree that the fewer abortions and unintended pregnancies, the better. The way we do that is not through mandated ultrasounds, but through better access to healthcare.

Q: You’ve championed Medicaid expansion in Virginia – discuss why.

Medicaid expansion is part of the Affordable Care Act (ACA), which we estimate would allow coverage for about 400,000 working Virginians. I always underline the word ‘working’ because these are people who work several jobs but the cost of healthcare has risen much faster than their wages, so they don’t have coverage. Without coverage, they tend to go to the ER, which is expensive.

Morally, it’s the right thing to do. There are also about 25,000 uninsured and underinsured veterans in Virginia who have risked their lives for our freedom, and the least we can do for them is to make sure they have coverage. From a business perspective, every day that we don’t expand Medicaid, we’re literally handing about $5 million to our neighboring states. We’ve

been eligible to expand Medicaid since January 2014, so we’ve forfeited over $2 billion.

As taxpayers, we all have sent money to Washington to support the ACA. All we’re trying to do is bring that money back to Virginia. It’s federal money that would cover people up to 133 percent of poverty levels – those who make too little or too much for coverage. It would also help our rural hospitals; probably a third of our rural hospitals currently are operating in the red.

Q: Discuss your Population Health initiatives.

The other area I’m working on is population health. We applied for, and were awarded, a State Innovation Model grant. I chaired the task force for that.

We’re looking at metrics to measure outcomes, and the system is going from a quantity-based reimbursement system to more of an outcome incentive. We’re trying to stay ahead of that curve. (See “Keeping Populations Healthier” in the September/October 2015 issue of Chesapeake Physician). We looked at the different metrics, and we’re in the process of completing that and will come out with a final report in a few months.

Q: Governor McAuliffe recently announced a partnership between Inova Health System and George Mason University to advance personalized health. What do you hope to achieve?

I’m excited about personalized health.

With the partnership between Inova and George Mason, we have an opportunity in Virginia to be world leaders. When you look at the three pillars of healthcare – quality, access and cost – how do we address the cost? We already talked about quality and outcome-based medicine, but we should also move to personalized healthcare.

We’re moving through biotechnology and data collection and analysis to the point where we can do genetic testing on an individual with cancer, looking at markers, proteins, etc., and say exactly

what kind of cancer they have. We have data for those that have come before you, what’s worked and what hasn’t. That’s good for both quality and cost. Rather than treating epilepsy with a medication that may not work or may cause side effects, if I know genetically what type of epilepsy they have and how best to treat them, I can hit the nail on the head the first time.

This is the whole premise behind the Inova partnership. Different health centers across the state will cooperate – EVMS in Norfolk, VCU here in Richmond, the University of Virginia in Charlottesville, Carilion in Roanoke, and the medical system in Blacksburg. So we can

I really want to drive personalized health and make Virginia a leader.

– LIEUTENANT GOVERNOR R A L P H N O RT H A M , M D

collaborate and have the numbers, the data and the analysis. It will bring in big researchers, and with those researchers come grants, and that creates opportunities for businesses to develop around them.

Q: What is your position on treating epilepsy with medical cannabis?

We did a lot of work on medical cannabis last year. Several types of epilepsy, Dravet and Lennox-Gastaut syndrome, respond to this. We learned last year that we weren’t allowed to use cannabis oil (one of at least 85 active cannabinoids) in Virginia, which tends to be fairly conservative. The mother of one of my patients stepped up to the plate and got others involved. We reached out to all the legislators, and we were able to pass legislation last year allowing its use in Virginia. We’re participating in a research study in East Virginia Medical School, where I teach and practice.

For 18 years, I’ve also been the medical director of Edmarc, a pediatric hospice in Hampton. That’s something that’s really put my life in perspective. The worst thing any family can go through is the loss of a child. It’s sad at times, but when families put their trust in you at that time in their life, it’s also very rewarding.

Everyone should have advance directives.

It’s difficult for the family and also difficult for providers if we don’t know what the person’s wishes were. It’s both a quality and a cost issue. Think of what we spend in the last weeks of a person’s life when they may not have wanted to prolong life like that. People usually don’t want to be hooked up to tubes and machines.

Q: You’ve announced your intentions to run for governor. Are you actively campaigning?

Yes. I just didn’t have enough going on!

What we also need to talk about is the FitBit Challenge. There are about 10 of us, including myself, and the Governor’s wife.

I’ve gone 150 miles in 12 days. I do about 28,000 steps in a day and I ran five miles this morning. I intend to literally run for governor.

Q: What are the initiatives you’d like to continue if elected governor?

My goal is a prosperous and healthy Virginia. It’s all about economic development and having good businesses and good jobs, because that’s what drives the economy. Governor McAuliffe and I have been very successful at creating jobs.

He has a tremendous amount of energy.

We want to incentivize and maintain good businesses and also attract new ones.

I also want to create a healthier Virginia.

I really want to drive personalized health and make Virginia a leader. And make sure our children have opportunities and get off to a healthy start. Neurologists tend to be mediators and healers. I like to bring people from different sides of the aisle to find common solutions, and move Virginia forward. CP

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H E A LT H C A R E I T

CONNECTED HEALTH AND

For the past three years, Chesapeake Physician has attended the HIMSS mHealth Conference in Washington, DC, to report on the latest trends in healthcare mobile technology. This year, the conference was renamed Connected Health to reflect its broader scope and its integration with a CyberSecurity and Population Health Summit, with the goal of creating more transformative mobile healthcare approaches.

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THE INTERNET of THINGS he latest buzzword – the Internet of Things (IoT) – was on lots of lips at the conference.

An app that stood out from the conference crowd was SmokeBeat, a data-analytics software platform that works with standard smartwatches and wristbands to identify, in real time, when users are smoking and take them through an effective smoking cessation process. An app developed by a Chesapeakeregion physician for diagnosing and treating concussions is also highlighted here.

The Internet of Things (IoT) is yet another healthcare acronym, albeit one shared with other industries. While definitions vary, it refers, essentially, to connected smart sensors. A 2015 MarketResearch.com report projects that the healthcare IoT market will be worth $117 billion by 2020, and healthcare is expected to be among those industries that benefit most.

The applications of IoT are numerous, spanning from the increasingly ubiquitous smartwatches to home monitoring equipment to sensors that can promote hand washing in a hospital. Hospitals are also using IoT to track patients, equipment and staff. For example, radio frequency identification tags (RFID) are being used in combination with mobile scanners and the ‘cloud’ to track medical inventories and reduce the need for costly overstocking.

Real-time location systems (RTLS) use geolocation technology embedded in a smartphone or navigation system to track shared equipment such as infusion pumps, wheelchairs and defibrillators. And clinical staff in the PACU can determine where patients are in the ER or OR to predict their arrival in the ICU, or medical surgical staff can predict when patients might arrive from the PACU. The IoT also has the potential to improve drug management by adding RFID tags to medication containers, and around the corner is the ability to embed the technology into the medication to create smart pills that monitor medication usage.

Innovative Smoking Cessation App An intriguing new app unveiled at this year’s conference uses real-time identification of hand-to-mouth gestures such as those used in smoking to improve healthy behaviors. Given that smoking kills nearly half a million Americans each year, and that smoking cessation is one of the hardest ‘prescriptions’ for patients to follow, a meaningful mHealth approach to cutting back is intriguing.

According to the CDC, as of 2010, about 42 million adults in the U.S. smoked, and the number was growing about two percent per year. While roughly seventy percent of smokers want to quit, only half of them actually try to quit, and only about six percent succeed. Mobile technology has proven helpful for promoting the adoption of healthier lifestyles, including helping them monitor

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BY LINDA HARDER

A smoking cessation app uses real-time data to improve healthy behavoirs.

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Joining Forces With Employers and Insurers Using the data provided by Somatix, companies can determine which programs are most effective, get insights on their employees’ or members’ habits, and customize reports to meet their needs.

Because smoking is linked to so many diseases, a growing number of employers and insurers are willing to pay people to cut back.

“Companies are willing to pay up to $1,500 per employee to address smoking in their employees,” Ofir states. Some large companies, such as IBM and others, spent tens of millions in internal campaigns and cessation programs for their staff.“We can provide incentives for people to smoke less and set goals by the number of cigarettes they smoke or the dollars they spend. We can do predictive analytics so that we know when a person is likely to smoke, based on his location, timing habits or people he is with, and suggest healthier alternatives to a cigarette.”

Currently, a few heath insurance companies, clinics and employers are using SmokeBeat in pilots outside the U.S. The company is taking its first steps in the U.S., presenting its platform to employers, clinics

Gerard Gioia, PhD, Children’s National Health System

and other related organizations in the healthcare system.

Insurers, employers and clinics can analyze the data collected via the app, get a dashboard report and offer personalized health plans, combined with incentives that work and positively influence the cost of healthcare for their members, employees or patients.

Potential Interventions in Eating Disorders, Substance Abuse Perhaps the most exciting aspect of the technology offered by Somatix is its potential to ameliorate health problems such as eating disorders, manage medication and alcohol consumption, or help people care for older relatives. For example, analyzing movements involved in consuming food, drinking or even vomiting

We can provide incentives for people to smoke less and set goals by the number of cigarettes they smoke or the dollars they spend. – E R A N O F I R

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smoking cessation, we also can help them join a group, or create their own supporting group of friends and family.”

Ofir and his colleagues combine the data with tailor-made incentives to quit.“We provide four types of incentives: rational, social, financial, and emotional. We can measure the responsiveness of each person to these different incentives and find what is most motivating for them.”

While SmokeBeat is hardware agnostic and runs on most smartwatches and wristbands available, it initially is available only to users of Android phones, but will soon be available to those with iOS. PRESTON KERES, CHILDREN’S NATIONAL HEALTH SYSTEM

their activity or quit smoking, but a new app called SmokeBeat takes that help to another level of sophistication.

The app was launched by an Israeli company called Somatix in November 2015, after it analyzed the motions involved in smoking a cigarette. According to Eran Ofir, CEO of Somatix, SmokeBeat is the first app to use the power of hand-tomouth gesture recognition by using an accelerometer and a gyroscope to identify when a user is smoking.

The company has been thoughtful in its approach to designing this app, using behavioral psychology based on sound academic research. After analyzing the movement patterns and speeds involved in smoking a cigarette, it uses a complex algorithm to determine when the handto-mouth gesture involves smoking a cigarette versus eating, drinking or another activity. While not perfect, it’s helpful for the average person, whom Ofir claims underestimates how much they’re smoking by 30 percent.

The goal is not necessarily to have the person quit smoking completely, but to have them understand how much they’re smoking, when, where and why, and to decrease how much they smoke through personalized incentives.

Ofir says,“Most people think they smoke less than they actually do. SmokeBeat helps them track their smoking habits, including the number of cigarettes they smoke, where they smoke most, when and why.”

He adds,“Our goal is harm reduction.

Every cigarette decreases a person’s lifespan by 11 minutes. Because social support is the biggest factor in successful

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Families love it because they don’t have to remember what to ask or what to look for. - G E R A R D G I O I A , P H D using the gyroscope and accelerometer could theoretically allow medical professionals to track how much an anorexic is eating or when someone with bulimia is purging. For frail older adults, the device has the potential to monitor how much they eat and drink, helping caregivers intervene earlier to prevent serious health problems.

Youth Concussion Assessment Apps Gerard Gioia, PhD, pediatric neuropsychologist and director of the SCORE Concussion program at Children’s National Health System, collaborated with colleagues at University of North Carolina at Chapel Hill and PAR, Inc., to develop smartphone and tablet apps for youth coaches, parents, athletic trainers, and other healthcare professionals to help them

CME/CEU credits available for purchase by qualifying attendees!

Organic Acids Workshop Philadelphia

recognize and respond to concussions.

The free app for youth coaches and parents, Concussion Recognition & Response (CRR), is based on information that Dr. Gioia developed with the Centers for Disease Control and Prevention’s Heads Up initiative (cdc.gov/headsup). Parents and coaches answer basic questions about the athlete’s signs and symptoms to determine if he or she has suffered a suspected concussion, and receive recommendations for the appropriate next steps.

Dr. Gioia explains,“The app creates a good assessment and communication tool for parents and coaches. The information logged into the app can be emailed to the pediatrician or ER provider, or can be printed out. As a clinician, this kind of information is hugely helpful.”

The app has been downloaded by tens

of thousands of people.“Families love it because they don’t have to remember what to ask or what to look for. The app guides them through the process. It’s like the ‘911’ of concussions,” Dr. Gioia comments.

A separate but related app for health professionals, called the Concussion Assessment and Response™: Sport Version (CARE-Sport Version), helps athletic trainers, team physicians and other qualified professionals assess the likelihood of a concussion, rule out cervical spine injury, evaluate cranial nerve function and respond appropriately. CP Eran Ofir, CEO of Somatix Gerard Gioia, PhD, pediatric neuropsychologist and director of the SCORE Concussion program at Children’s National Health System, Washington, DC

ORGANIC ACIDS WORKSHOP - Philadelphia

June 18, 2016 | Crowne Plaza Philadelphia - Cherry Hill The Organic Acids Test (OAT) from The Great Plains Laboratory is a diagnostic tool that every healthcare practitioner should know about. Whether you are a family practitioner, internist, neurologist, pediatrician, psychiatrist, or nutritionist, the information available from the OAT can be applied to any practice. The OAT provides a comprehensive and accurate snapshot of your patients’ metabolism. More than ever, patients are looking for integrative treatment options for their health concerns. The OAT will greatly enhance your diagnostic abilities with your patients.

WHY OUR ORGANIC ACIDS TEST?

Our Organic Acids Test is the most comprehensive available, with exclusive markers including those for HPHPA and oxalates, which are highly correlated with many chronic illnesses. Our OAT includes 74 markers, such as those for yeast and bacteria overgrowth, inflammation, oxidative stress, mitochondrial dysfunction, gastrointestinal dysbiosis, and nutritional imbalances. Folate metabolism markers (also found in the OAT) are gaining considerable interest in the autism community, showing that treatment of the MTHFR metabolic pathway can lead to significant reduction in autistic symptoms.

WHY ATTEND THIS WORKSHOP?

If you are looking for new ways to help patients with difficult-to-diagnose and chronic health issues, this workshop will greatly improve your skills. Dr. Woeller will not only show you how the OAT can be used in clinical practice, but ways to use it along with other diagnostic assessments.

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Near the Chesapeake Bay, boats are moored in the St. Mary’s River on a spring morning – a sign that the best fishing days of the year are approaching.

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