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Medical Science Writer, Progressnotes Magazine

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Chronic pancreatitis (long-standing inflammation of the pancreas) (CP) is a challenging disease for health care practitioners because it is difficult to diagnose and treat. Although its annual incidence rate in the United States is low (five to 12 per 100,000 persons), hospital admissions due to CP are on the rise. CP is characterized by severe abdominal pain and irreversible damage to the pancreas.

In the past decade new medical and surgical treatments have emerged that enable multidisciplinary teams to better recognize and manage this disease. In 2014, gastrointestinal specialists at the Medical University of South Carolina (MUSC), led by David B. Adams, M.D. (pictured below), professor of surgery and an expert in CP, organized the first international exchange of information on these advancements.
Dr. David B. Adams
The "2014 International Symposium on the Medical and Surgical Treatment of Chronic Pancreatitis" brought together experts from the fields of medicine, surgery, psychology, physiology, pharmacology and genetics.


Examples of breakthrough information from the meeting include:

  • New research findings about the causes of CP and its pain pathways
  • Updates on the endoscopic management of CP
  • Updates on total pancreatectomy combined with auto islet transplantation

Last month, a textbook covering the information that came out of that meeting was published (Wiley-Blackwell, April 2017). "Pancreatitis: Medical and Surgical Management" (ISBN: 978-1-118-91712-1) covers acute pancreatitis (sudden inflammation that lasts a short time) as well as CP. Adams is the chief editor. Co-editors are Peter B. Cotton, M.D., professor of medicine at MUSC; Nicholas J. Zyromski, M.D., associate professor of surgery at Indiana University School of Medicine; and John A. Windsor, MBChB, M.D., professor of surgery at Mercy Hospital in New Zealand.

The book provides gastroenterologists and gastrointestinal surgeons with an evidence-based approach to the most recent developments in the diagnosis and clinical management of pancreatitis. In addition to new surgical procedures such as endoscopic biliary intervention and minimally invasive necrosectomy, these advances include medical therapies, such as antiprotease, lexipafant, probiotics and enzyme treatment.

"This book is the latest information from international experts in all of the relevant disciplines of medicine," says Adams. "This represents the first time all of these experts have come together to share their knowledge and experience."

MUSC will host a second international CP symposium in 2018 in Charleston, South Carolina. International experts from the fields of medicine, surgery, psychology, physiology, pharmacology and genetics will confer and exchange ideas to identify the direction, trends and developments in the diagnosis and management of CP that are needed to enhance clinical effectiveness, encourage adoption by healthcare providers, and engage patients in best practice and cost-effective care.

For more information, visit http://www.pancreatitissymposium.org.

graphic for macular degenerationOne approach to treating retinal diseases such as age-related macular degeneration is transplantation of the cells under the retina, i.e., the retinal pigment epithelium (RPE), but life-long immune suppression drugs are required to prevent rejection. Researchers using induced pluripotent stem cells (iPSC) have demonstrated alternatives that do not trigger rejection, but that process uses viruses to introduce the desired reprogramming factors. Currently, the U.S. FDA has not allowed clinical trials using virally generated iPSC.

A team of Medical University of South Carolina (MUSC) scientists led by Lucian V. Del Priore, M.D., Ph.D., Pierre Gautier Jenkins Professor in the Department of Ophthalmology, has demonstrated a successful alternative to viral induction--exposing skin cells to human proteins—and reported on these results in the November 25, 2015 PLOS ONE. This alternative lays the groundwork for providing a safer way to generate RPE cells for transplantation.

“This works because ultimately the DNA creates a protein inside the cell, which then affects the cell’s behavior,” explains Del Priore. The efficiency is low; only about 1% of cells become transformed, he reports, but the research established that these cells can then be turned into RPE and that these cells function normally in the Petri dish. Specifically, the work demonstrated that the generated RPE can ingest outer segments from the retina, which is important in the normal maintenance of this delicate neural tissue. Work on this project involved a collaborative research team that included Ernesto Moreira, M.D.; Jie Gong, M.D., Ph.D.; Mark Fields, Ph.D., MPH; and Zsolt Ablonczy, Ph.D.

Another team led by Del Priore reported on a "chemical peel" of the substrate under the RPE, which is damaged by retinal disease as well. Successful transplantation depends upon a healthy substrate. The investigators’ successful rejuvenation of the tissue was reported in Translational Vision Science and Technology 2015 (Oct 30;4(5):10. 

image of scannerMUSC Health has brought the latest in Positron Emission Tomography (PET)/CT scanner technology to the U.S. with the Department of Radiology’s new scanner that offers 128-slice CT.  The mCT 128 PET/CT system (Siemens Healthcare, Erlangen, Germany) enables nuclear medicine specialists to see anatomical images, such as lung nodules, and physiologic functions, such as coronary blood flow, in greater detail. This diagnostic advantage will be especially beneficial in three clinical areas, according to Leonie L. Gordon, M.B., ChB, Director of Nuclear Medicine. These specialists will use the scanner to interpret images in (1) cancer diagnosis (to locate tumors and metastases to other organs and bones) and treatment adjustment (with clearer pictures of the tumor’s borders, they can better advise surgeons planning to resect cancerous tissue or help medical oncologists change chemotherapy if it has been ineffective ); (2) heart disease diagnosis and treatment (to better assess cardiac muscle viability and the degree of blockage in coronary vessels, for example); and (3) neurological disease (to confirm the diagnosis of dementia, identify epilepsy seizure locations, and assess treatment effectiveness in certain  brain tumors). 

Furthermore, this scanner is more patient-friendly. Scanning time is reduced from an average of 45 minutes to 15 to 20 minutes, a feature especially advantageous for patients from MUSC Children’s Hospital. “Because the scanner is quicker, children may not need to be sedated,” says Gordon.

Combined PET/CT scanning has been commercially available since 2001. Its advantage is that it fuses the PET and CT information into one image and almost complete eliminates the false-positive and false-negative PET findings. The mCT 128 PET/CT system is different in that the CT provides 128 detector rows (slices) of anatomical images, as opposed to the 64 slices or fewer in older technology. This system has been available in Europe for 2 to 3 years. Siemens chose MUSC Health as the first hospital in the U.S. to receive the system because of its history with MUSC Health specialists’ clinical development and evaluation of Siemens equipment. This system is FDA-approved, but MUSC Health will be evaluating further the clinical utility of putting such a high-resolution CT scanner with a PET scanner. Gordon predicts the system will be of particular benefit to the patients at MUSC Hollings Cancer Center and MUSC Health Heart & Vascular Center.

Photo of Lyles and Student
Mark Lyles, M.D., MBA, Chief Strategic Officer, MUSC Health, and president-elect of the American College of Medical Quality (right) with Martin Wegman, M.D.--Ph.D. student from the University of Florida, and immediate past chair of the ACMQ student-resident section (left) at the October 23 meeting.

Years ago, health care quality management was a narrow field owned primarily by the rare physicians and researchers who specialized in medical quality. Now, professionals from many health care fields are focusing on medical quality, says Mark Lyles, M.D., MBA, FACMQ, Chief Strategic Officer, MUSC Health, and president-elect of the American College of Medical Quality (ACMQ). “What used to be a niche field has now gone mainstream,” he says. In 2014, the ACMQ opened its membership to include clinicians, administrators, and other professionals who focus on all areas of medical quality.  Any health care professional who holds a master’s degree or higher – or who is training in such a program – may become a member of the ACMQ.

Therefore, in collaboration with MUSC’s College of Health Professions, the ACMQ sponsored a workshop on “The Art of Leadership” as part of the 2015 MUSC Health Care Leadership Conference on October 23, 2015 in Charleston, SC. The conference was attended by more than 190 administrators, executives, clinicians, information technologists, leaders, faculty, and students in the health care industry.

As follow-up to this successful meeting, Lyles is now working closely with Sydney Ramsey, a second-year medical student at MUSC, to establish an ACMQ interprofessional and interdisciplinary chapter at MUSC. The first of its kind in the country, the ACMQ chapter at MUSC will be open to students from all of its six colleges; faculty advisors will work closely with these trainees to educate them about the important roles that medical quality now plays in all aspects of the health care professions.

Watchman deviceMUSC Health is the first hospital in South Carolina to offer a left atrial appendage (LAA) closure device that reduces stroke risk for high-risk patients with non-valvular atrial fibrillation. The WATCHMAN™, (Boston Scientific Corporation, Marlborough, MA) approved by the U.S. Food and Drug Administration in March 2015, is intended for percutaneous transcatheter closure of the LAA. Six of these devices have been implanted at MUSC Health by Frank A. Cuoco, M.D., MBA, Director of the Cardiac Electrophysiology Lab. “In atrial fibrillation, most blood clots that are responsible for stroke form in the LAA,” he says. “Implanting this device has been shown to be equivalent to warfarin for overall stroke prevention and superior to warfarin for reduction of bleeding and overall cardiovascular mortality.” Six weeks after implantation, patients are able to stop warfarin. They remain on clopidogrel and aspirin for 6 months while the device completely seals, and then require only aspirin going forward. This therapy offers a proven alternative to patients who cannot or do not want to use warfarin to reduce their risk of stroke.

the Sinu-lok device

The Medical University of South Carolina’s Institute for Applied Neurosciences (IAN), a technology accelerator that was created in 2013 to develop neuroscience technologies, has licensed its first medical device.  Amendia, based in Marietta, Georgia, has acquired the exclusive worldwide rights to manufacture and sell Sinu-Lok™, a rod implant used in minimally invasive lumbar spinal fusion surgery. In this procedure, the screws that will connect the rod implant are extra tall to allow for smaller incisions when putting them in. Today’s standard rod implant is slightly bowed. When the surgeon tightens the construct down, the rod’s curvature forces the top part of the tall screws to bump together or even overlap. This puts stress on the construct components, which can lead to a loosening of the construct after the surgery and other complications.

Alternatively, the Sinu-Lok rod has a smooth oscillating shape that provides several concave locations in which the screws can seat when tightened. This patented shape also provides an extended range of axial connections between the screw-rod interface when the construct is tightened, creating a divergence of the screw towers instead of the convergence caused by the standard rod.

The licensing of Sinu-Lok is a key milestone for IAN, says Ted Bird, Chief Development Officer for IAN. “This license validates our unique technology acceleration model and demonstrates our ability to develop, patent, and commercialize valuable health care ideas from MUSC. Sinu-Lok was the first product developed and patented by IAN and we are very pleased to have a commercial partner like Amendia that is committed to manufacturing and commercializing this product as soon as possible to benefit surgeons and ultimately patients.”

IAN has seven additional active projects in the areas of concussion detection, neurovascular cranial access systems, brain tumors, spine surgery, intra-operative neuro-monitoring, and general surgical devices, as well as a current pipeline of 10 potential projects being reviewed.

Illustration by Emma Vought

Photo of veteranA study among military veterans needing psychotherapy for depression has demonstrated that such therapy delivered via telemedicine in patients’ homes achieves outcomes that are not significantly inferior to those of traditional in-person clinical encounters.1 In their editorial in the August 2015 The Lancet Psychiatry, Hoge and Rye describe this study as the kind of rigorous clinical trial that is necessary to establish acceptable standards of care, calling it “a vanguard of demonstration of safety and efficacy of in-home telemental health.”  All research team members were affiliated with the Medical University of South Carolina (MUSC) or the Ralph H. Johnson Veterans Affairs Medical Center in Charleston, SC. The Principal Investigator was Leonard E. Egede, M.D., Professor of Medicine at MUSC, Director of the MUSC Center for Health Disparities Research, and the Director of the Charleston VA HSR&D Health Equity and Rural Outreach Innovation Center. In the 2007 - 2011 study (NCT00324701), 204 veterans aged 58 years and older were treated via either telemedicine or same-room treatment. Their response to the treatments did not differ significantly. The researchers’ interpretation of this data, which is in the same issue of The Lancet Psychiatry2, is that evidence-based psychotherapy delivered to patients in their homes is not only not inferior, it is advantageous because it overcomes distance, attendance, and stigma barriers faced by some veterans. "This is the first study in the elderly that shows that in-home telemedicine works as well as face-to-face sessions for the treatment of depression,” says Egede. “It provides strong evidence for using in-home telemedicine to treat depression and possibly other mental health conditions in those with stigma or mobility challenges, the home-bound, or those who are geographically isolated and cannot get to care easily. In addition, there were no adverse events, which have always been a concern for mental health treatment delivery via telemedicine.”

1 Egede LE, Acierno R, Knapp RG, et al. Psychotherapy for depression in older veterans via telemedicine: a randomized, controlled, open-label, non-inferiority trial. The Lancet Psychiatry 2015; 2(8): 693-701.

2 Hoge, CW, Rye, CB. Efficacy and challenges of in-home telepsychotherapy. The Lancet Psychiatry 2015; 2(8): 668-669.

Physicians in a discussionThroughout the nation, payers’ penalties to hospitals for readmissions are driving numerous initiatives to improve care transitions. South Carolina’s acute care facilities have come together to create a statewide quality improvement learning collaborative named Preventing Avoidable Readmissions Together (PART). Eligible participants include all acute care hospitals and home health organizations, nursing facilities, hospices, and other health care organizations. The results of PART’s initial 18 months (September 2012 to February 2014) are profiled in an article published ahead of print in Population Health Management (June 23, 2015) at http://online.liebertpub.com/doi/10.1089/pop.2014.0182). The authors include Patrick J. Cawley, M.D., Executive Director/CEO of MUSC Medical Center and Vice President for Clinical Operations at MUSC; and R. Neal Axon, M.D., Associate Professor in the Department Medicine at the Medical University of South Carolina.

The majority of the state’s acute care hospitals (92%) and hospital systems (90%) participated in collaborative events that included webinars and coaching calls, in-person meetings, and individualized peer consultations. The PART leadership team developed and distributed a resource guide to all interested organizations. Progress reports and outcomes analyses were also shared. At the completion of year one, 58% of participating hospitals completed a survey. Rates of implementation of the best practices that had been suggested were as follows: complete implementation of multidisciplinary rounds (58%), post-discharge telephone calls (58%), teach-back (32%), in-process implementation of high-quality transition records (53%), improved discharge summaries (45%), and timely follow-up appointments (39%). As for outcomes, a higher proportion of hospitals reported significant decreases in all-cause readmission rates for acute myocardial infarction, heart failure, and chronic obstructive pulmonary disease. The authors explain why certain readmission data should be interpreted with caution, and point out that the full effects of PART participation are probably not yet realized.

leddy and surgery team preparing prosthesisIn May 2015, an 8-year-old boy from Columbia, SC became the second child in the state to receive an extendible implant that replaced the leg bone that osteosarcoma had destroyed.  Orthopaedic oncologist Lee Leddy, M.D., Associate Professor in the Department of Orthopaedics at MUSC Health, performed the surgery, removing the cancerous bone (and its growth plate) and replacing it with a device designed to be lengthened over time to ensure that both legs will be of equal length. During follow-up visits every four to six weeks, the boy will place his leg into a doughnut-shaped magnet that will drive a gearbox to extend the prosthesis nine centimeters, the remainder of the boy’s projected growth.

Prior to this technology, options for a child whose growth plate had to be removed due to cancer were amputation; rotationplasty, in which the child’s ankle is substituted for the knee joint; or implants that required repeated surgeries to lengthen the prosthesis.  With this device, future operations are not necessary. More than 100 procedures have been completed in the U.S. with this device, but only two in South Carolina, both by Leddy at MUSC Health.

Leddy says this prosthesis is a dramatic improvement over the ways doctors previously met the challenges of limb salvage surgery in the skeletally immature patient. “Being able to reliably lengthen the extremity without surgery is a major advantage,” he says. “However, it is important to realize how critical the team approach is when treating these complex problems.”

The team of specialists who collaborated on these complex cases included musculoskeletal radiologists who interpreted radiographs and magnetic resonance imaging reports,  pathologists who evaluated biopsy tissues, sarcoma-trained surgical oncologists who helped resect the cancer and reconstruct the extremity, operating room nurses, oncologists who made recommendations regarding chemotherapy, and physical therapists who worked with the patients to help return them  to their active lives.

Leddy says that assuming a good response to chemotherapy and physical therapy, these patients can expect a full recovery. 

Photo provided by Sarah A. Pack

image accompanying chronic pancreatitisIn the last decade, total pancreatectomy with islet autotransplantation (TPIAT) has emerged as a means for treating selected patients with chronic pancreatitis (CP). This specialized procedure, undertaken in a complex group of patients, requires a multidisciplinary team of physicians including gastroenterologists, endocrinologists, GI surgeons, behavioral medicine specialists, and others. To establish the best standard of care, representatives from these disciplines gathered in 2014 near MUSC at an international symposium organized by David B. Adams, M.D., Professor in the Department of Surgery. This event led to a July 2014 workshop sponsored by the National Institute of Diabetes and Digestive and Kidney Disease in which specialists focused on research gaps and the best management of TPIAT.  Common themes included the need to identify which patients best benefit from TPIAT and when to intervene with TPIAT, its current limitations, diabetes remission and the potential for improvement, opportunities to better address pain remission, GI complications, and unique features of children with CP considered for TPIAT.  A summary of these discussions published in the January 2015 Annals of Surgery was co-authored by Katherine A. Morgan, M.D., Chief of the Division of Gastrointestinal and Laparoscopic Surgery at MUSC.  A subsequent paper also authored by Morgan (in the April 2015 Journal of the American College of Surgeons) shares the results of a study on quality of life outcomes (physical and psychological) for TPIAT patients.

As a result of this initial collaboration, pancreatic specialists from various institutions and disciplines have formed a research consortium to further explore TPIAT.

MUSC is recognized as a leading institution in the management of CP and in the research and understanding of the best application of TPIAT.

Silhouette of joggersClinicians often underutilize exercise and pulmonary rehabilitation as a therapy for lung cancer patients and survivors, but investigators from MUSC Health have found that physical activity is safe, well-tolerated, and beneficial at every stage of lung cancer. Their findings are reported in the Journal of Thoracic Oncology (March 30, 2015). The researchers – Gerard A. Silvestri, M.D., MS, Professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at the Medical University of South Carolina, and Brett Bade, M.D., a Fellow in the Division of Pulmonary, Critical Care, and Sleep Medicine – reviewed more than 100 studies that examined the effects of exercise on cancer patients.  “We found that physical activity reduces the risk of cancer development and the symptom burden as the disease progresses,” says Silvestri. The authors advised clinicians to consider physical activity early, counsel against inactivity, and encourage physical activity for patients in all stages of lung cancer and for survivors.  

Scientists and engineers at the Institute for Applied Neurosciences at MUSC Health have developed a device that detects mild traumatic brain injury, also known as concussion.  Previously, there was no objective way to identify concussion, leaving clinicians and athletic trainers with only subjective measures of altered behavior or cognitive function.  The Blink Reflexometer uses stimuli to trigger a blink and a high-speed camera to collect data on the body’s response to these stimuli.  When a blow to the head occurs on the athletic field or battlefield, for example, trained personnel can use this device to stimulate and record a blink, then compare the person’s data to his or her baseline measurement (recorded previously in the Blink Reflexometer). The technology is now being refined into a hand-held device and the research team is collecting baseline measurements on football players from The Citadel and Charleston Southern University. Clinical trials will continue through Fall 2015. This device is expected to be commercially available by approximately 2017. 

For neuroendovascular surgeons treating intracranial aneurysms, two of the most difficult to treat are bifurcation aneurysms arising at the basilar apex or the carotid terminus.  Until recently, effective techniques that could be applied with acceptable risk were available only outside the U.S.  In June 2014, the U.S. Food and Drug Administration (USFDA) approved an investigational device exemption for the PulseRider® (Pulsar Vascular, San Jose, CA), a reconstruction device intended for wide-neck aneurysms at or near a bifurcation of the basilar tip or carotid terminus.  The first three U.S. cases were done by Alejandro M. Spiotta, M.D., Assistant Professor in the Department of Neurosciences, Raymond D. Turner, M.D., Associate Professor in the Department of Neurosciences, and M. Imran Chaudry, M.D., Associate Professor of Radiology at the Medical University of South Carolina (MUSC). They were able to achieve complete occlusion of the aneurysm without intraprocedural complications in all three cases. These cases are part of a multicenter clinical trial currently being conducted at eight select centers in the U.S. The trial is ongoing and patient enrollment is scheduled to end in late fall 2015. Dr. Spiotta and co-authors reported on these results in the January 5, 2015 issue of the Journal of Neurointerventional Surgery

smoker and lungs illustrationCertain smokers covered by Medicare have a new preventive service benefit. On February 5, 2015, the Centers for Medicare & Medicaid Services (CMS) published its decision to cover counseling and an annual Low-Dose Computed Tomography screening of current and former smokers who meet eligibility requirements. Those include being between 55 and 77 years of age, having no signs or symptoms of lung cancer, having a smoking history of at least one pack per day for 30 years, and being a current smoker or one who has quit smoking within the last 15 years. Cancer specialists who recommended approval of this benefit in October 2014 before the CMS’s Coverage and Analysis Group in Woodlawn, MD included Gerard A. Silvestri, M.D., MS, Hillenbrand Professor of Thoracic Oncology in the Division of Pulmonary and Critical Care Medicine at MUSC Health. More information here.

fowler - terriThe MUSC College of Nursing’s online graduate nursing program was recently ranked number one in the nation by U.S. News & World Report. Ninety six nursing programs were scored on factors such as graduation rates, academic and career support services offered, and admissions selectivity. MUSC earned an overall score of 100.  College of Nursing Dean Gail Stuart, PhD, says the achievement “is a reflection of the dedication of our faculty and staff.” 

The College of Nursing began its asynchronous online program in 2006 with the Master of Science in nursing (MSN) and the Doctor of Philosophy (PhD), followed by the Doctor of Nursing Practice (DNP) in 2009, and the Registered Nurse to Bachelor of Science in nursing (RN-BSN) in 2014. There are currently almost 300 students enrolled in the online graduate programs.  

ecigarette imageThe use of electronic nicotine delivery systems (ENDS), which include e-cigarettes, is on the rise, but authorities in cancer research and tobacco policy are not ready to recommend them as a safe way to quit smoking.  Twelve experts from cancer research institutions developed a national policy statement published January 8 in two prominent cancer journals, Clinical Cancer Research and the Journal of Clinical Oncology.  The authors, who include Graham W. Warren, M.D., PhD, Associate Professor of Radiation Oncology at the Medical University of South Carolina, caution that E-cigarettes are not regulated by the FDA and may be harmful, particularly to youth.  “E-cigarettes are a rapidly evolving product and we simply don't know if they help people quit smoking or if they increase the risk that people will start or continue smoking, such as when people start trying e-cigarettes in their youth,”  says Dr. Warren.

The authors recommend further research on these devices, regulation of ENDS, requiring FDA oversight and warning labels on products and advertisements, prohibiting marketing to youth, and prohibiting ENDS use in places where cigarette smoking is prohibited.  

One of the latest developments in laser technology, stereotactic laser ablation, is now enabling neurosurgeons at the MUSC Medical Center to treat brain lesions and tumors that were previously inaccessible. In December, they used Visualase (Medtronic, Inc., Minneapolis, MN), an MRI-guided laser system, to remove tumor tissue in the brain of an adult male. He was able to leave the hospital the next day due to the fact that the procedure was minimally invasive. In the past, a patient with his type of lesion would have required an open craniotomy and would have spent a week recovering in the hospital. Instead, with this new technology, surgeons use a small hand drill to make a 3.2 mm opening in the skull and then thread in a 1.65 mm flexible laser applicator.  The small incision is typically closed with one suture.

More importantly, the Visualase technology enables the surgeon to reach deeper regions of the brain, target tumors precisely, and protect healthy tissue by monitoring the temperature of the tumor and the surrounding tissue.

The Visualase system is used in hospitals throughout the United States but only at MUSC Health in South Carolina. In children, the device has also been used to treat brain lesions that cause epilepsy. 

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