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The Male Factor Diagnosing and treating male infertility
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LVAD Implants Hope for a failing heart
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Exploring Medical Horizons
Managing Graftversus-Host Disease Better bone marrow transplant outcomes
Raising the Bar 6
Cerebral hemorrhage in the brain
University of Utah Stroke Center First in State to Earn New Certification
NEW FRONTIERS
FORGING NEW FRONTIERS TOGETHER On behalf of the physicians at University of Utah Health Care, I want to welcome you to the inaugural issue of Frontiers, a quarterly publication designed to introduce the physician community of the Intermountain West to the dedicated health care providers who staff our hospitals, community clinics and specialty centers. Our physicians, representing more than 200 medical and surgical specialties, partner with referring physicians throughout the region and around the globe to tackle the challenging, complex cases that may require highly specialized treatment. You have a relationship and a history with your patients. Our goal is to complement the care you proSEAN J. MULVIHILL, M.D. vide your patients with the expert, compassionate care CEO of University of that a signature academic medical center can offer. Utah Medical Group Our commitment is to keep you informed and involved and director of clinical operations as we partner with you in their care. for University of Utah Our premier issue highlights the efforts of some of Health Care our outstanding physicians and their care teams. The Blood and Marrow Transplant Program team is developing a multidisciplinary clinic to monitor and treat patients who have chronic graft-versus-host disease. This effort involves outreach to referring physicians to help them recognize early signs of complications in their patients. Our Cardiac Mechanical Support and Heart Transplant team, led by one of the nation’s most prominent cardiac surgeons, performs advanced procedures such as implanting ventricular assist devices to extend the lives of congestive heart failure patients. Our Stroke Center team recently earned certification as a Comprehensive Stroke Center, the first and only center in Utah to do so. Finally, at the Utah Center for Reproductive Medicine, we’re pleased to welcome James M. Hotaling, M.D., M.S. He is the first specialist in male infertility to practice in Utah, offering a rare expertise in microsurgical techniques. Please contact frontiers@hsc.utah.edu to learn more about our specialists and how we can collaborate with you to better serve your patients. Sincerely,
Sean J. Mulvihill, M.D.
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Editorial Director Dennis Scott Jolley, Senior Director of Clinical Marketing Managing Editor Edwin V. Lyons, Program Manager email: edwin.lyons@hsc.utah.edu Contributors Sean J. Mulvihill, M.D.; Jill Austin, R.N.; Erin Davis, R.N.; Gerhardt Hildebrandt, M.D.; James Hotaling, M.D., M.S.; and Craig Selzman, M.D. McMurry/TMG Senior Editor: Janice Sweeter Senior Art Director: Adele Mulford Art Director: Pamela Norman Writers: Janette Bowers and Alicia Greenleigh
Frontiers is published quarterly by University of Utah Health Care for physicians and should be relied upon for medical education purposes only. This publication does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient. © 2014 University of Utah Health Care. All rights reserved. Produced by McMurry/TMG. Contents of this publication may not be reproduced without the express written consent of University of Utah Health Care.
383 Colorow Drive Salt Lake City, UT 84108 healthcare.utah.edu
Cover: Scott Camazine/Getty
University of Utah Health Care was recognized by The University HealthSystem Consortium as a top 10 principal academic medical center in the U.S. and a recipient of the UHC Quality Leadership Award for the fourth year in a row.
WINTER 2014 VOLUME 1, ISSUE 1
FRONTIERS IN EXPERTISE
Focus on the Male Factor Urologist brings rare infertility expertise to Utah
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icrosurgical techniques and other advanced treatment options for male factor infertility could be helping many couples achieve pregnancy, if only they and their physicians knew about them, says James M. Hotaling, M.D., M.S. “It’s kind of sad, really. A lot of guys will go to their primary care doctor or their urologist, and following a semen analysis, they’ll hear, ‘You’ll never be able to have your own kids.’ And that’s where the road ends.” In fact, a trained specialist using microsurgical testicular sperm extraction (micro TESE) can find and retrieve sperm in about 70 percent of men who have no sperm in their ejaculate, Hotaling says. The first physician in Utah to specialize in male infertility, Hotaling recently joined the Center for Reconstructive Urology and Men’s Health at University of Utah Health Care. He previously completed a fellowship in male infertility at the University of Illinois at Chicago, where the bulk of his time was spent performing micro TESE and other microsurgical techniques. Surgery isn’t always the answer. “I want to use the least amount of technology as possible. If I can put them on medicine and improve their sperm count, that’s fine. It is less expensive than surgery, which is important if they are considering in vitro fertilization (IVF).” In Hotaling’s view, what’s most important is having a fellowship-trained specialist evaluate the man. Diagnosing and treating the male factor “can have a real impact on the rate of pregnancy achieved through IVF, which has already improved dramatically over the past 20 years,” he points out. While he prefers to have the man’s wife or female partner present (because “they ask many more questions than men do”), he does not treat women. Rather, his goal is REFER YOUR to optimize PATIENTS James M. Hotaling, the man’s reproM.D., M.S., sees ductive potential to patients at the give the couple the best Utah Center for outcome possible. “I’m Reproductive happy to see patients Medicine in Salt Lake from any referring City and at the South provider, and the Jordan Health Center. men I see will go right To refer a patient, call back to that provider, 801-587-3772. Learn once the male factor more at healthcare. has been addressed,” utah.edu/andrology Hotaling says. ■
JAMES M. HOTALING, M.D., M.S. Assistant professor of Surgery, Division of Urology, University of Utah School of Medicine
Charlie Ehlert/University of Utah Health Care
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FRONTIERS IN COLLABORATION
Re-Energized and Back to Work LVAD implants on the rise for patients with congestive heart failure
The HeartMate II LVAD is placed surgically next to the failing heart and restores blood flow to the entire body. The HeartMate II LVAD has been implanted in more than 15,000 patients worldwide.
The HeartMate II LVAD is about 3 inches long and weighs about 10 ounces.
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n March 2012, Bill Deist came down with a simple, run-of-the-mill cold. Or so he thought. When his symptoms persisted for months, he decided it was time to see a doctor. What he discovered was a rare case in which a cold virus had begun to attack his heart. The effects were quick and merciless: In just two months, Deist lost significant weight, had a hard time walking around the house and was always out of breath. “I didn’t have the strength, the get-up-and-go, that I’m used to having,” Deist, 63, says. “I felt like I was losing control, and like I had to rely on other people in ways I never had to before.” Deist’s primary care physician in Winnemucca, Nev., diagnosed congestive heart failure and recommended that Deist go to University Hospital, where he was evaluated by Craig H. Selzman, M.D., a nationally known, board-certified cardiothoracic surgeon and researcher. “By the time we saw Mr. Deist, he was decompensated to the point where he was unable to tolerate standard medical therapy: beta blockers and ACE inhibitors,” Selzman says. “He required intravenous inotropic medicines to augment his heart functions and keep him out of heart failure.” Deist could have continued his IV therapy at home, Selzman says, “but he was still feeling quite poor and we wanted to get him better. Plus, the medical therapy carries a pretty high mortality rate over six to 12 months.” Implantation of a left ventricular assist device (LVAD) offered the best hope for long-term support of Deist’s failing heart, Selzman says. The hospital is performing the procedure with increasing frequency, he adds. “When I came here five years ago, we were doing five or six LVADs a year; this year we’ll come close to 70,” he says. “We’ve followed patients with these pumps over five call years, and they are Learn More About very stable. So Mr. Cardiothoracic Deist could go five Surgery for Your to 10 years with this Patients device, if not longer.” To refer your In Deist’s case, the patient or get more LVAD is also helping information, please to decrease the blood contact the University of Utah Health Care pressure level in his Cardiovascular Center lungs (pulmonary at 801-585-7676 or hypertension is a visit healthcare.utah. common side effect edu/cardiovascular/ of heart failure). heartsurgery.
“I appreciate and admire Dr. Selzman a lot,” Deist says. “He made a point of stopping by personally every day I was at the hospital to check up on me. He didn’t have to do that, but to receive that kind of care and attention was a wonderful thing.” After the implant, Deist was able to return to his full-time position as a city manager. His primary care physician monitors his condition and calls Selzman’s team at the hospital if questions arise. Deist returns to the hospital every six months for a careful evaluation, Selzman says. “Because our patients come from 13 different states, we try to educate physicians in the local communities to provide as much care as they can so that the patient doesn’t have to fly to Salt Lake City for every minor issue,” he explains. “If the local physician wants to accept the challenge of caring for this patient, we support them as much as possible. For the most part, these are just normal patients except for the fact that they have this device implanted.” n
Craig H. Selzman, m.D. Surgical director, Cardiac Mechanical Support and Heart Transplant Program, University of Utah Health Care; associate professor of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine
Winter 2014
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Frontiers in innovation
Raising the Bar Stroke center first in Utah to earn new certification
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or the University of Utah Stroke Center team, earning the state’s first Comprehensive Stroke Center Certification is more than just an achievement. It culminates a commitment by every physician, nurse and staff member to provide the best stroke care to patients in the Intermountain West. Administered by DNV Healthcare Inc., a federally recognized accreditation authority, the process of becoming a Comprehensive Stroke Center began with a step-by-step review of each clinical area within University Hospital’s continuum of stroke care: ≥ Diagnosis ≥ Treatment ≥ Rehabilitation ≥ Education According to Jill Austin, R.N., B.S.N., nurse manager for the stroke center, achieving the status of Comprehensive Stroke Center means a higher level of stroke care, expanding upon the familiar Primary Stroke Center certification. “Our stroke program provides 24/7 neurovas“The Comprehensive Stroke Center Certification cular and neurosurgical interventions provided by establishes clear metrics beyond those required by board-certified specialists. The neurointerventional Primary Stroke Center certifications, and it serves and neurosurgical suites within University Hospital as a guide by which our clinical success is evaluare state-of-the-art,” Austin explains. ated,” Austin says. “Because time is of the essence In addition to requiring acute for every stroke patient, we are now therapies, the comprehensive certifiable to more rigorously track how Call cation guidelines call for participation long it takes to assess and diagnose, Learn More in clinical research and structured as well as treat, each case. We also outpatient follow-up. “Our stroke review our outcomes constantly to University of Utah Stroke Center is program is involved with several NIH ensure that our treatment intervenpart of the Clinical research projects, both acute and tions are timely, effective and of the Neurosciences long-term studies,” Austin says. “We highest quality.” Center at University feel that our stroke program offers A DNV-certified Comprehensive of Utah Health excellent care, based on evidenceStroke Center has demonstrated Care. To learn more about the center’s based research and clinical guidethat its stroke program has estabservices, including lines. The Comprehensive Stroke lished standards of excellence and the telemedicine Center Certification validates the sucbest practice that directly affect program for rural and cess of our program, which, in turn, access to and delivery of the highest underserved areas directly impacts patients’ lives.” n level of stroke care available. of the Intermountain
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West, call 801-587-9935.
Brain scan imagery of a cerebral hemorrhage.
FRONTIERS IN CONNECTIONS
Fighting the Enemy: Graft-Versus-Host Disease Vigilant follow-up detects complications after bone marrow transplant
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or patients who receive allogeneic bone marrow transplants, the ordeal of preparing for and undergoing the procedure is often the beginning of a long journey. “For many patients with cancer of the blood and lymph system, bone marrow transplants can give the only chance for cure. Yet the procedure often doesn’t end with finding a donor and receiving the cells,” says Gerhard C. Hildebrandt, M.D. “Everyone who has an allogeneic bone marrow transplant is at prolonged risk of developing graft-versus-host disease (GVHD) and other transplant-related complications. Early identification and thorough follow-up are critical. Both acute and chronic GVHD carry a high risk of morbidity and mortality and may involve multiple organ systems,” Hildebrandt says. Some signs of GVHD, such as skin changes, can be identified more easily, but others, such as lung problems and chronic fatigue, may be misinterpreted or missed, says Hildebrandt. “Lung involvement is a much bigger problem than initially thought, and it’s often not recognized as a complication of chronic GVHD until quite late, when the disease is advanced and harder to treat. A multidisciplinary approach is important to improve outPREVENTIVE PIT STOPS comes for our patients.” n A new program, currently evolving, takes a two-pronged approach to successful long-term management of GVHD.
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The Multidisciplinary Chronic GVHD Clinic/BMT Long-Term Survivorship Clinic, together with cancer survivorship specialist Anna C. Beck, M.D.*, will establish a formal structure for systematic follow-up, “where patients would come here as though making a pit stop at certain points in time, get thoroughly checked, and go back with instructions for their referring physicians,” Gerhard C. Hildebrandt, M.D., explains. “Easy access for patients, their families and their health care providers will be key.”
GERHARD C. HILDEBRANDT, M.D. Medical director, Huntsman Cancer Institute Blood and Marrow Transplant Program; associate professor of Medicine, University of Utah School of Medicine
LEARN MORE For more information about the Huntsman Cancer Institute Blood and Marrow Transplant Program, call 801-585-2626 or visit huntsmancancer.org/bmt.
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Steve Gschmeissner/Science Source
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Hildebrandt plans an outreach effort to inform and educate referring physicians and their teams about the multiple diagnostic and therapeutic aspects of chronic GVHD, so they can become active partners in the long-term care of their transplantation patients. In addition to providing post-transplant survivorship care plans and offering access to clinical trials and specialists at Huntsman Cancer Institute and University of Utah School of Medicine, members of the BMT team may tour the Intermountain West to meet with health care providers who are interested in learning more about GVHD. The goal, Hildebrandt says, is that these physicians and advanced practice clinicians will “watch for the symptoms, identify them early, and send the patient to us when complications are suspected. We can always get the patient in.”
Bone marrow transplant, conceptual image. Composite colored scanning electron micrograph of bone marrow cells, preparing for infusion during the transplant procedure.
*Anna Beck, M.D., medical director, Supportive Oncology and Survivorship; and associate professor of Medical Oncology, University of Utah School of Medicine.
Winter 2014
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Briefs RECOGNITIONS
WILLIAM T. COULDWELL, M.D., PH.D. Professor and chair, Department of Neurosurgery, University of Utah School of Medicine
William T. Couldwell, M.D., Ph.D., was named president of the American Association of Neurological Surgeons (AANS) at the association’s annual meeting in April 2013, after completing a one-year term as president-elect. One of his goals as president, he says, is to encourage neurosurgery residents to take advantage of the many clinical and research opportunities available to them. Another is to attract more of the country’s top medical students, particularly women, to consider neurosurgery as a specialty. “We attract the best and brightest medical students, but neurosurgery has traditionally been a male-dominated field. Probably less than 10 percent of practicing neurosurgeons are women,” Couldwell says. “Because half of the
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medical students in the country are women, we want to make sure we’re attracting half the talent.” He points to a “renaissance in our specialty,” noting that advances in technology and expertise have enabled neurosurgeons to perform procedures like deep brain stimulation for movement disorders and Parkinson’s disease, “diseases that we were never able to treat before. It’s a magical time.”
STEFAN-M. PULST, M.D., DR. MED. Professor and chair, Department of Neurology, University of Utah School of Medicine
Stefan-M. Pulst, M.D., Dr. Med, will receive the George C. Cotzias award, one of the premier neuroscience awards of the American Academy of Neurology (AAN). He will deliver the Cotzias Lecture at the annual meeting of the AAN on April 29, 2014. His topic will be “Degenerative Ataxias: From Genes to Therapies.”
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Share your news, recognitions, awards and . events in upcoming issues of Please send to frontiers@hsc.utah.edu.