UC Health Team Haiti Eyes a Deepening Commitment
At the hospital, from left (standing): translator and hospital employee Jean Kensy Simbert, EMT, Sarah Winston, MD, and Margaret Spears, RN; from left, sitting: Eric Anderson, EMT-P, and Mallorie Boeing, RN. Photos courtesy of UC Health Team Haiti. It wasn’t a one-time deal. The one-week medical mission to Haiti in 2011 didn’t turn out to be an experience of a lifetime that provided perspective, assuaged the conscience, and allowed Cincinnati clinicians to say they’d done their part. In January 2012 an even larger group went back, and they stayed twice as long. UC Health Team Haiti, it appears, is just getting started. Jordan Bonomo, MD, a specialist in emergency medicine and neurocritical care at the UC Neuroscience Institute and a veteran of international medicine, and Jessica Wiles, RN, BSN, Clinical Education Program Developer in the Emergency Department at University Hospital, led 42 individuals* in the return trip to Port-au-Prince and Bernard Mevs Hospital/Project Medishare, Haiti’s only hospital dedicated to intensive care and trauma. The Cincinnati team was divided into two groups, with most members working one week between Jan. 7 and 21, but some working two. The doctors, nurses and paramedics came from UC Health, Cincinnati Children’s Hospital Medical Center and Good Samaritan Hospital. Team members purchased their own airline tickets and used vacation days to cover their time away. Looking ahead, Dr. Bonomo said this week that he envisions not only a standing rotation of one- or two-week mission trips, but also opportunities for training Haitian clinicians. “They need us to come as educators,” he said. “I can imagine our efforts out of UC Health splitting into two groups: those who want to go and serve and be part of a mission, and those who want to teach and provide advanced training in, say, ultrasound. In Haiti they can use an ultrasound when no X-ray or CT is available. This may be how we make a broader and more lasting impact. “We have so much to give,” he continued. “We go as a team, as friends, with the same academic model. It’s what we do here … there.” Getting the team ready for a mission is something like readying a platoon for battle. For Ms. Wiles, the team’s coordinator, it’s a labor of love. “From administering vaccinations, anti-malarial drugs and HIV prophylaxis to gathering supplies and securing passports and documentation of licenses, the to-do list can seem endless,” Ms. Wiles said. “But at the end of the day I am tremendously grateful for the time and talent that our team dedicates to our missions, so the extra effort it takes to organize seems small in comparison to the gains. “The more daunting challenge,” she added, “is the realization that many of our team members obtain their very first passport to attend this mission. Taking a group to a place like Haiti as their first experience outside the country doesn’t come without risk, but our team did a fantastic job adapting and embracing the Haitian culture.” This year UC Health Team Haiti found Bernard Mevs Hospital in better condition than the year before, but with still-humbling facilities that included 2 emergency department beds, 3 ICU beds, 9 medical beds, a 7-bed spinal cord unit, 2 ventilators, and a single, balky CT scanner that worked sporadically. There was no EEG machine with which to confirm that a patient’s seizures had stopped, and even IV tubes were in short supply. “You didn’t start an IV unless you were absolutely positive you’d get it,” said Sarah Barno, RN, a nurse in the Emergency Department at UC Health. “Nothing could be wasted.” Meanwhile, two years after the catastrophic earthquake, heartbreaking triage continued to take place outside a front gate protected by heavily armed guards. Opeolu Adeoye, MD, a specialist in emergency medicine and neurocritical care at UCNI, would point to one patient – yes, you come in – and then to another – no, you cannot come in. Recalled Dr. Bonomo: “The hardest part was saying to someone, ‘You can’t come in,’ and hearing him respond in English, ‘Then where am I supposed to go?’ ” In a city of 4 million, there was not enough room for all. Nevertheless, members of UC Health Team Haiti treated hundreds of patients while also providing valuable education to hospital staff. “I think for us to have this role as UC Health employees is very impressive,” Dr. Adeoye said. “We saw just about everything, including emergent operative cases. We saw abdominal perforations, gunshot wounds, surgeries, neurological cases, traumatic brain injury, status epilepticus, ischemic strokes.” The team’s patients included a 21-year-old American volunteer who was riding in the back of a truck outside Port-au-Prince while traveling to a mission project when he was shot and left bleeding. Pooja Khatri, MD, Associate Professor of Neurology at UC and a physician at UCNI, discovered that she was the first neurologist to work at the hospital in several months. “Haiti reminded me of how much I enjoy being a doctor because there was so much to do and I felt so useful,” she said. “I had to think so differently. CT scans are taken for granted here. But in Haiti our scanner wasn’t dependable. Sometimes it worked, and sometimes it didn’t. So we didn’t know what was going on in people’s brains. Sometimes we had to make our best guesses. “One patient in particular made me feel really useful. There was a question about whether he had a spinal cord injury, but after spending a lot of time with him I realized he did not have a spinal cord injury but rather an unusual complication of syphilis that we don’t usually see in the United States. I physically went into the pharmacy and shuffled through a box of antibiotics and was able to find the medicine he needed.” At the end of each day, Dr. Khatri found herself tallying up how she had made a difference. “And part of me thought that was really egotistical,” she reflected. “But I
Neuroscience Expert: Challenges Ahead, But “Research Bandwidth” Can Expand
Guest lecturer Dennis Choi, MD, PhD, right, with Fredy J. Revilla, MD, Director of the Gardner Center at UCNI. Dr. Choi was Dr. Revilla’s mentor and department chairman at Washington University in St. Louis about a decade ago. Photo by Cindy Starr / Mayfield Clinic. The esteemed neuroscientist Dennis Choi, MD, PhD, special guest lecturer at the University of Cincinnati (UC) College of Medicine, on Thursday issued a warning about funding for neuroscience drug research and expressed his hope for a new model of collaboration involving the National Institutes of Health, academic health centers like UC, and the pharmaceutical industry. He called for “increased bandwidth” in the number of ideas that can be converted into active research, and he said that foundations can play a more proactive role in disease philanthropy. The Harvard-educated Dr. Choi, who took a leave from his faculty position at Emory University to serve as Executive Vice President of the Simons Foundation, is uniquely positioned to make such far-reaching pronouncements. He has held leading neurology posts at Washington University in St. Louis and Emory University in Atlanta, and he served as Executive Vice-President of Neurosciences at the Merck Research Lab from 2001 to 2006. The Simons Foundation, based in New York City, supports a significant initiative in autism research known as SFARI. Speaking to a roomful of clinicians and researchers, many of them affiliated with the UC Neuroscience Institute, Dr. Choi described the complexities involved in knowing whether a drug will be effective. Will the body absorb it? Will it hit the target without causing cancer? Spending more time and money understanding the biological and molecular infrastructure of a disease, he said, might help researchers zero in on therapies that are likely to be successful. He noted that the cost to industry of launching a new drug in 2004 was $1.78 billion, a staggering amount that can cause tension between the needs of society and the demands of shareholders. Dr. Choi witnessed firsthand the costly, time-consuming process of working potential drugs forward at Merck, where, he said, people joked that “a standard unit of chemists” was 20 chemists. As global investment in drug discovery has soared and productivity has diminished, he said, Wall Street has taken notice, and pharmaceutical stock prices have sagged. “If you had sold one of your shares of Pfizer and bought Apple a couple of years later,” he said, “your stake in Apple would be worth nearly $15,000.” “What’s of particular concern,” he continued, “is that neuroscience is taking it on the chin. “There is a major failure scenario, and the way you know that is several companies have closed their neuroscience efforts. So this is actually a crisis. If society is allowed to stop developing therapeutics for nervous system diseases, it is an ominous step for the future of mankind.” Dr. Choi described the current situation as “a failure of the free-market system” that is nevertheless entirely solvable by changing regulatory rules so that the business case for investment is improved. Dr. Choi also put forward a new research model. In today’s “linear model,” he said, where NIH and foundations fund basic research at academic institutions and discoveries are then passed to industry to develop drugs and test them in clinical trials, “the bandwidth is maxed out, and I fear that at our current pace we’re leaving all kinds of good ideas on the table.” The only way to increase “the bandwidth of exploration” in a time of limited resources, he said, is to change to an integrated, multidirectional model in which both funding agencies and academic medical centers join industry in driving clinical exploratory testing. As an example he pointed to the study of progesterone as a possible medical treatment following traumatic brain injury. The study originated in Emory’s department of emergency medicine, where researchers had long talked about the promise of progesterone. Without government or corporate funding, the researchers decided, “Let’s just test it ourselves.” The small pilot study supported the hypothesis that progesterone reduced mortality, and today the National Institute of Neurological Disorders and Stroke, a division of NIH, is funding a national, multi-site study of progesterone known as ProTECT III. UC Health / University Hospital is a study site, with efforts led by Jay Johannigman, MD, Professor and Director of the Division of Trauma and Critical Care, and Lori Shutter, MD, Professor of Neurosurgery and Neurology and Director of the Neurocritical Care Program. Foundations, likewise, can play an important role, Dr. Choi said. “Instead of sitting passively in the background solely funding investigator-initiated research projects, more and more foundations are stepping forward into more proactive roles, and so you see more and more of them blur the line between their scope of operations and those of biotechnology companies. It was my fascination with this sector’s progressive engagement that caused me to take my leave of absence from Emory and work with the Simons Foundation.” — Cindy Starr
Dr. Alberto Espay Eyes a Year of Olympic Potential
Alberto Espay, MD, leads a session of video rounds for faculty, fellows and residents in the Department of Neurology at the UC College of Medicine. Photo by Cindy Starr / Mayfield Clinic. For Alberto Espay, MD, the year ahead is going to require a feat of gymnastics. A neurologist at the James J. and Joan A. Gardner Family Center for Parkinson’s Disease and Movement Disorders and a researcher who is leading seven clinical trials, Dr. Espay is attracting global recognition for his wide-ranging talents and is being pulled in all directions. He is in demand as a writer, an editor, a speaker and – somersaulting up onto the balance beam now – as one of those think-on-your-feet professors with a flare for teaching, showmanship and diagnosing complex conditions while hundreds of people watch. The Gardner Center is part of the University of Cincinnati (UC) Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health. Dr. Espay, who is also Associate Professor and Director of Clinical Research in UC’s Department of Neurology, was recently named one of six assistant editors at the journal Movement Disorders. He will be the Movement Disorders Society’s Ambassador to the Americas, which will take him to Mexico and Argentina later this year. He is co-chairing the second International Conference on Knowledge Gaps in Parkinson’s Disease and Movement Disorders in February near Portofino, Italy; he is chairing the creation of the World Atlas of Movement Disorders, under the sponsorship of the Movement Disorders Society, slated for publication in 2013; and he is starting his third book. “What drives Alberto is his passion to understand his patients and creatively find solutions for their disorders of movements,” says Joseph P. Broderick, the Albert Barnes Voorheis Professor and Chair of the Department of Neurology and UCNI’s Research Director. “He is an outstanding example of the kind of physicians who are part of the University of Cincinnati Neuroscience Institute and UC Health.” Creativity will be set on high alert when Dr. Espay serves as one of 15 professors in the Neuro Bowl at the American Academy of Neurology’s annual meeting in New Orleans in April, and as one of 10 movement disorders experts from around the world in the Video Olympics at the Congress of Movement Disorders meeting in Dublin, Ireland, in June. “The year is going to present a double gymnastics, as there are two events that are geared toward rapid acumen and are a bit like game shows,” Dr. Espay says. “The Academy of Neurology provides very short vignettes that cover the entire sphere of neurology, while three teams strive to make the correct diagnoses and vie for the title of Neuro Bowl champions. At the Congress of Movement Disorders, two five-member teams assess cases that have been culled from submissions from around the world.” Some of the movement disorders cases are so difficult, Dr. Espay says, that the treating neurologists may not have known the answer until after the patient had passed away and an autopsy was performed. “Sometimes the expectations are not that you will come up with the correct diagnosis but that you can rationalize your thought process and approach,” Dr. Espay says. “You are showing the audience how a professor or expert in the field approaches a challenging case, from sifting through all the symptoms to prescribing a diagnostic procedure to narrowing it down to one or two conditions. The team with the greatest diagnostic accuracy or most thoughtful differential wins the Video Olympics trophy.” Group diagnosis of complex conditions is such a valuable educational tool that Dr. Espay brought the concept of video rounds to the Gardner Center in 2006. Short video clips of patients are shown, and residents and fellows are required to think their way through the subtleties of multiple, inconclusive symptoms. Dr. Espay, who will be appearing in his third Neuro Bowl and first Video Olympics, recalls watching the Neuro Bowl several years ago and thinking, “There is no way I would ever enjoy being in the panel.” But once invited, with his aptitude and gregariousness, he was a perfect fit. Less public, but more valuable, is Dr. Espay’s role as assistant editor. His fellow assistants are from Canada, England, Spain and, in the United States, from the University of Pennsylvania and the Mount Sinai School of Medicine. Dr. Espay earned the prestigious position because of his reputation as a prolific peer reviewer (56 papers over the last two years). While he will receive no pay for this work, he says he is honored “to have the civic responsibility.” In reading research papers, he says, he is looking first and foremost for relevance. “How is this going to change the way I care for my patients, the way I approach my next patient, and does the material change my practice?” he asks. “So many papers confirm facts that we already know. If I would say to you, I have shown that bradykinesia — slowness of movements — improve with the drug levodopa because I’m measuring it with a new fancy device, you haven’t told me anything new about the disease or its treatment. A study of this sort has low relevance and will probably not meet publication threshold. On the other hand, if you have a device that is going to help patients walk better, that’s a different story altogether. That changes our understanding of disease or how we approach treatment.” And that, of course, brings Dr. Espay back to his patients. In the end, the research, the publications, the papers with relevant data, the papers with irrelevant data, even the gymnastics, are all about them. — Cindy Starr
Sad? Anxious? Really, It’s All in Your Head!
NAMI Executive Director Heather Turner with Stephen Strakowski, MD. Photo by Cindy Starr / Mayfield Clinic. Shake it off … Everybody goes through bad patches … Chin up … It’s all in your head! Sound familiar? Stephen M. Strakowski, MD, a leading psychiatrist and researcher, knows that for those who struggle with mental illness, dark thoughts and cloudy moods really are all in their head. But – and here’s the catch – they’re biologically based and not a sign of moral failing or personal weakness. “The brain,” he said Wednesday, “is vulnerable to going awry.” Dr. Strakowski, Senior Associate Dean for Research at the University of Cincinnati, the Dr. Stanley & Mickey Kaplan Professor and Chairman of Psychiatry and Behavioral Neuroscience, and head of UCNI’s Mood Disorders Center, discussed mental illness in an evolutionary context and condemned stigmatizing attitudes at the 2011 Annual Celebration of NAMI Hamilton County. The organization is one of more than a hundred local branches of the National Alliance on Mental Illness. Like a new automobile or the latest computer model, the part of our brain that houses the newest and most complex machinery is most apt to have a bug in it, Dr. Strakowski said. “Our big foreheads – the prefrontal cortex – is what makes us human,” he said. “We’ve only had these big foreheads for 50,000 years, whereas we’ve been walking around for 4 million years. The newest part of the brain is the least tested over time.” The new brain, he added, “has matured late, and it’s the seat of most, if not all, mental illness.” Dr. Strakowski said problems arose with a breakdown of feedback loops between the newer prefrontal cortex and two very old parts of the human brain. The older parts involved in this misfiring are 1) the striatum, which drives us for reward and pleasure, and 2) the amygdala, which drives our “fight or flight” response. In the modern world, the amygdala fires when we argue, become emotional or experience stage fright. “These deep brain structures are closely connected to the prefrontal cortex,” Dr. Strakowski said. “The prefrontal cortex modulates and manages primitive impulses. Ninety-five percent of our decisions are based on how we feel, but as human beings we are able to nuance our feelings so that eventually our emotions make good decisions for us.” Functional MRI, a medical test that produces images of the brain in action by revealing electrical activity, shows that in people with bipolar disorder, the amygdala is overactive even in situations when the brain is processing a simple task. This results in serious mood swings, from abnormally elevated or energized moods (mania) to depression. Looking out over a packed dining room at the Hyde Park Country Club, Dr. Strakowski said that the audience – a record 225 for NAMI’s annual celebration — showed that “people are finally starting to get it.” Mental illness, which accounts for five of the 10 most disabling conditions in the world, is vitally important, he said. The world’s most disabling conditions, according to “The Global Burden of Disease” (Harvard University Press, 1998), are: 1. major depression; 2. iron-deficiency anemia; 3. falls; 4. alcohol abuse; 5. chronic obstructive pulmonary disorder; 5. bipolar disorder; 7. congenital anomalies; 8. osteoarthritis; 9. schizophrenia; and 10. obsessive-compulsive disorder. In summary, people who pejoratively dismiss depression or other mental illness as being “all in your head,” are uneducated about the biological mechanisms underlying the disease. “Stigma is always based on ignorance,” Dr. Strakowski said. “Typically, the most stigmatizing people know the least about what they’re talking about.” Dr. Strakowski encouraged his audience to continue working to “spread knowledge and help people understand these illnesses.” * * * Among those receiving 2011 Awards of Excellence at the NAMI event were: Scott Bullock, MSW, LISW-S, Lindner Center of HOPE, “Exemplary Therapist” James Curell, MD, Associate Professor of Clinical Psychiatry at UC, “Lucille Pederson Hardgrove Exemplary Educator” Save the date: NAMI Walks at Sawyer Point, May 12, 2012. — Cindy Starr
To Save Patients from Metastatic Brain Cancer, Expert Says, Control the Astrocytes
Dr. Isaiah Fidler presenting the inaugural lecture of the UC Brain Tumor Molecular Therapeutics Program. Photo by Cindy Starr / Mayfield Clinic. Isaiah Fidler, DVM, PhD, one of the world’s leading experts on brain metastasis, wowed a standing-room-only audience of neuroscience researchers Wednesday at the University of Cincinnati by illuminating what he hypothesizes is the lethal, long-hidden culprit behind brain metastasis. The villain turns out to be a group of brain cells known as astrocytes – vitally important to human health in good times but destructive when confronted with cancer cells that have migrated (metastasized) from another part of the body, such as the breast or lung. Astrocytes, which exist only in the brain, communicate with encroaching cancer cells and then, in a cascade of untoward biological events, confer immunity upon the cancer cells, making them resistant to chemotherapy. The result: most patients who experience brain metastasis succumb in a matter of months. Dr. Fidler, Distinguished Chair in Cell Biology and Head of the Metastasis Research Laboratory in the Department of Cancer Biology at the University of Texas MD Anderson Cancer Center, presented his hypothesis in the inaugural lecture of the UC Brain Tumor Molecular Therapeutics Program, which is a part of the UC Brain Tumor Center and a close affiliate of the Mayfield Clinic. Dr. Fidler is also serving as an external advisor to the program’s new Scientific Advisory Board. “The major death from cancer is not from a primary tumor but from metastasis,” Dr. Fidler said. “Metastasis is the ultimate expression of cellular anarchy. Metastases develop and survive because they exploit cells for their own gain.” Resistance to chemotherapy has long been blamed on the “blood brain barrier,” Dr. Fidler noted. Scientists have theorized that the brain protects itself from toxic substances, including beneficial substances like chemotherapy, by effectively locking them out and thereby preventing them from permeating the brain. But Dr. Fidler disputes that theory. Pointing to an image of enormous, leaky blood vessels in a metastatic brain tumor, he noted that the blood vessels had ample permeability, so a barrier could not be the problem. “Think about it,” Dr. Fidler said. “By the time we make a diagnosis, vessels in brain metastases are leaking. So the blood brain barrier is not an explanation for resistance, at least not for me. So I look for a different reason for resistance, and I’d like to blame the astrocytes. “Astrocytes have essential function,” he continued. “They transport nutrients from the blood to neurons (brain cells), they protect neurons, they participate in signal transmission, and they maintain homeostasis. Without astrocytes, a neuron will starve to death.” However, he said, when the brain experiences damage, the astrocytes become activated and somewhat manic in their effort to help out. When a cancer cell invades from the breast or lung or from a melanoma, he said, astrocytes produce “a knee-jerk reaction.” They communicate with the cancer cells – actually touching them with their tentacles – and produce endothelins, peptides that travel through the tentacles to the tumor cells and bind to cell receptors. At that point the tumor cells are able to up-regulate (increase the quantity of) three survival genes that ultimately protect the cancer cells from chemotherapy. The UC Brain Tumor Molecular Therapeutics Program, which was established in March 2011 with a $2 million gift from the Harold C. Schott Foundation and an additional $4.5 million in funding from UC, is a collaboration between the UC Cancer Institute and the UC Neuroscience Institute. Dr. Fidler agreed to serve as an external advisor because of his longtime interest in the metastatic process and because so few centers around the country are trying to understand and cure brain metastasis. “Dr. Fidler is likely the world’s No. 1 expert on metastasis,” said Olivier Rixe, MD, PhD, Director of the Experimental Therapeutics Program and Professor of Medicine in UC’s Division of Hematology-Oncology. “In the 1980s he discovered all the key mechanisms to explain how a primary tumor can metastasize to another organ. More recently, he has focused on brain metastasis and has put forth explanations for why brain metastases are more difficult to treat and how they develop drug resistance.” “Metastasis is a last frontier of cancer,” Dr. Fidler said, following the lecture. “Ten years from now, metastatic cancer will no longer be a black box.” While at UC Dr. Fidler also helped evaluate grant presentations and offered insight into future research strategies and recruitments. “We are fortunate to have Dr. Fidler visit to help us set our new Molecular Therapeutics Program on the right path,” said George Atweh, MD, Director of the UC Cancer Institute and Head of the Division of Hematology-Oncology. “We look forward to interacting with him and using his expertise to bring our program to the next level.” “By asking prominent researchers like Dr. Fidler to become external advisors who evaluate and sometimes guide our research, we hope to accelerate our efforts and improve our ability to help patients who suffer brain metastasis,” said Ronald E. Warnick, MD, Medical Director of the UC Brain Tumor Center and Chairman of the Mayfield Clinic. Dr. Fidler, a native of Jerusalem, chaired the Department of Cancer Biology at MD Anderson from 1983 to 2008. Prior to joining MD Anderson he served as head of the Biology of Metastasis Section at the National Cancer Institute’s Frederick Cancer Research Facility in Maryland. Dr. Fidler was working in veterinary medicine at the University of Pennsylvania when his career swerved in the direction of human metastasis. A “dog person and cat person” with a love of horses, Dr. Fidler was unhappy spending so much of his time putting down animals whose cancers had metastasized. In a typical scenario, an animal was cared for by the family vet and then brought to Dr. Fidler after the cancer had spread. Encouraged by his dean, Dr. Fidler left veterinary medicine, earned his PhD in human pathology at Penn and went on to become a supernova in the academic world. At 75,
Medication Risks Are Real for Pregnant Women with Epilepsy
Michael Privitera, MD, above, Director of the UC Epilepsy Center. Photo by UC Academic Health Center Communications Services. What’s a mother-to-be to do? That may be the question of the decade for women of childbearing age who have epilepsy. Do they risk having a seizure while pregnant? Or do they risk exposing their fetus to anti-epileptic medications? “This is a critical issue,” says Michael Privitera, MD, Professor of Neurology and Director of the Epilepsy Center at the University of Cincinnati Neuroscience Institute. “On the one hand, if a woman with epilepsy stops taking medication, she risks having seizures, which can hurt the fetus. On the other hand, we know that most of the antiepileptic drugs cause problems for the fetus. But our knowledge of the effects is imprecise, and the evidence base from which to make informed decisions in individual cases is limited.” For 11 years Dr. Privitera has served as the local principal investigator for an ongoing multicenter study of the adverse effects of antiepileptic drugs on the children of women who take them during pregnancy. Dr. Privitera helped design the study, and the UC Epilepsy Center has thus far enrolled more patients than any other academic health center site. Early findings from the study were profound: Children born to mothers who took anti-seizure medications known as valproate while pregnant may have impaired cognitive development. The news was so significant that it appeared as the lead paper, “Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs,” in the April 16, 2009 issue of the New England Journal of Medicine. And on June 30, 2011 the U.S. Food and Drug Administration followed up with a Drug Safety Communication that warned of the link between lower IQ and exposure in the womb to valproate sodium or related products. The FDA stated that, “Valproate products are FDA-approved drugs to treat seizures, and manic or mixed episodes associated with bipolar disorder (manic-depressive disorder), and to prevent migraine headaches. They are also used off-label (for unapproved uses) for other conditions, particularly for other psychiatric conditions. Valproate products include: valproate sodium (Depacon), divalproex sodium (Depakote, Depakote CP, and Depakote ER), valproic acid (Depakene and Stavzor), and their generics.” “The research found that even in the absence of obvious malformations like cleft palate or spina bifida, children born to mothers receiving valproate had statistically significant and clinically relevant reductions in IQ at age 3 compared to children born of mothers receiving other antiepileptic drugs,” Dr. Privitera says. As of 2007, valproate was still the second most commonly used anti-epileptic medication in women of childbearing age in the United States. Last week’s FDA warning, Dr. Privitera notes, is likely to change the way physicians treat women of childbearing age who have epilepsy. “It is rare that a study has such broad impact on the field,” he adds. At the Epilepsy Center, drug safety during pregnancy is an important part of treatment decisions, says David Ficker, MD, the center’s Associate Director and head of its New-Onset Seizure Clinic. “When we see new patients who wish to have children, we always discuss risk,” Dr. Ficker says. “Ideally, we want to prescribe treatment that is optimal for both the short- and long-term. If a woman hopes to have children five years from now, we want to find a medication that will work today and that also will be safe for her baby.” Still, the decisions for mothers and physicians are not always easy. Another anti-epileptic drug, carbamazepine, has been found to have an effect on the verbal abilities of children exposed in the womb. “Ultimately, there is much more research to be done,” Dr. Privitera says. “Someday, we hope to have tools that will enable us to select the optimal medication for each individual patient.” – Cindy Starr
Fourth Annual ‘Research Innovations’ Event Draws 500 Patrons
The fourth annual “Research Innovations for an Epilepsy Cure” drew some 500 guests to the glittering Mercedes-Benz of Cincinnati on Oct. 17. The indoor showroom, emptied of vehicles for the occasion, featured a dual silent auction, with gifts on the first floor and to-die-for wines above – including a 1982 Chateau Mouton Rothschild that sold for $970. The event benefits research at the Epilepsy Center at the University of Cincinnati Neuroscience Institute. Presenting sponsor was the Pamela and Charles L. Shor Foundation for Epilepsy Research. Diamond sponsors were Fifth Third Bank, Romiley and Thayer Jack, J.P. Morgan and the Shanahan Family. Platinum sponsor was the Schiff Family Foundation. Special guest was Hollywood screenwriter and vintner Robert Kamen. The organizing committee comprised Sally Lutz, Anne Shanahan, Pamela and Charles Shor, Michael Privitera, M.D., Susan Muth, Jameson Muth, Mendy Shaw, Jill Johnston and Jon Zipperstein. Event photos by Mark Bowen for the UC Epilepsy Center
Head & Neck Cancer Specialist Fears New Anti-Smoking Images May Fall Short
Photo of Yash Patil, MD, by Cindy Starr / Mayfield Clinic A picture may pack the punch of a thousand words, but Yash Patil, MD, doesn’t think the graphic images scheduled to appear on cigarette packs in 2012 will be strong enough to slay the dragon of nicotine addiction. In Dr. Patil’s experience, a diagnosis of cancer may not even be enough. “In a decade of treating patients with head and neck cancers, I’ve never met an addict who didn’t want to stop the day they received a cancer diagnosis,” says Dr. Patil, an otolaryngologist with the University of Cincinnati Neuroscience Institute and UC Health and an Assistant Professor of Otolaryngology at UC. But not all can free themselves from the vice-grip of addiction. At least one-third of the patients Dr. Patil treats for head and neck cancers are not able to stop smoking. That fact is borne out by one of the FDA’s most graphic images, which depicts a man exhaling smoke through a tracheotomy hole in his neck. “The addiction is very real,” Dr. Patil says, “and the greatest mistake we can make is to blame patients for their addiction and pass judgment. If they had heart disease, we wouldn’t pass judgment.” Robert Anthenelli, MD, Professor of Psychiatry and Psychology at UC and Director of the Tri-State Tobacco and Alcohol Research Center, says it is “the hallmark of addiction” that some patients with serious tobacco-related medical conditions, including head and neck cancers, continue to smoke despite knowledge that the smoking caused their cancer and continues to harm them. “This is a sign of the loss of control and continued use despite serious medical consequences that are symptoms of all addictive disorders, including nicotine dependence,” he says. The Food and Drug Administration is hopeful that the ads will help reduce the number of smokers, which stands at 20 percent of adults in the United States. On its Web site, the FDA describes the warnings as “a significant advancement in communicating the dangers of smoking.” Dr. Anthenelli believes the harsher warning labels on cigarette packs sold in the United States are long overdue. “The U.S. lags behind other developed countries in issuing such graphic warnings, which have been found to have some positive effects in motivating smokers to quit and preventing youth smokers from trying smoking.” Dr. Patil agrees that the ramped-up cigarette warnings, which will cover half the front and back of each pack, are likely to help dissuade some younger people from starting to smoke. He remains skeptical, however, because the allure of smoking has long been dispelled and that virtually everyone is aware of the harm that cigarettes cause. The most “bang for the buck,” Dr. Patil believes, involves educating very young children about the dangers of smoking. Dr. Patil recently delivered such a message himself in a 15-minute presentation to his son’s first-grade class. People who continue to smoke following a cancer diagnosis often suffer from what Dr. Patil calls “refractory addiction,” or treatment-resistant addiction. At the same time, these individuals are not expecting to develop cancer, he says. “Just because someone is addicted to something doesn’t make the diagnosis any less painful. It’s a common misconception that someone who smokes is expecting to develop cancer. They’re not expecting it. It is an absolute jolt and tragic turn of events.” Patients who develop head and neck cancer are treated at the UC Neuroscience Institute whether they are able to quit smoking or not. “If they’re actively smoking or drinking alcohol, we beg them to stop,” Dr. Patil says. “But once they have developed cancer, it has to be treated. We can’t simply wait the months and months it might take for them to stop.” * * * Anyone who smokes or who drinks heavily should see a specialist immediately if he or she experiences a change in voice or swallowing that persists for more than three to four weeks. * * * A new support group is available to patients at UCNI who are treated for head and neck cancer. To reserve a space in the group, please contact Angie Keith at (513) 475-7366 or [email protected] For information about smoking cessation, please visit: Tri-State Tobacco and Alcohol Research Center >> Win by Quitting, a program at the Barrett Cancer Center: (513) 585-CARE * * * The pain of oral cancer: Photograph of healthy mouth and (warning!) graphic photograph of mouth cancer. Click to view >> – Cindy Starr
Certified Stroke Centers Make a Life-Saving Impact
Congratulations to Jason Mackey, MD, and Dawn Kleindorfer, MD, on their authorship of “Stroke Centers and Quality of Stroke Care,” an editorial* in the May edition of the prestigious journal Neurology. Dr. Mackey, a second-year fellow in the Department of Neurology, and Dr. Kleindorfer, Associate Professor of Neurology and Director of the Division of Vascular Neurology, are members of the UC Cerebrovascular Disease and Stroke Center at UCNI and the Greater Cincinnati / Northern Kentucky Stroke Team. In their editorial, Drs. Mackey and Kleindorfer summarized highlights of a study of outcomes of primary stroke centers certified by the Joint Commission. Data about how patients fare when treated at primary stroke centers had been lacking. (The UC Neuroscience Institute, one of the earliest certified centers, was first certified in 2005 and was re-certified in 2007.) The study, led by Judith Lichtman, PhD, MPH, of Yale University, compared 30-day mortality and readmission rates of patients in certified hospitals to 30-day rates in uncertified hospitals in 2006. The patients were 65 and over and had suffered an ischemic stroke (a stroke caused by a blockage). Because the rates were similar – 10.7 percent mortality in certified centers vs. 11.0 percent in uncertified, with similar readmission rates – the study did not evoke a thunderous response. Nevertheless, as the authors pointed out, 49 percent of the certified centers had significantly lower rates than the national average, compared to only 19 percent of non-certified centers. Meanwhile, viewing the larger picture, Drs. Mackey and Kleindorfer noted that stroke treatment has improved significantly in recent years, with the death rate dropping 34.3 percent from 1997 to 2007. A study recently published by emergency medicine and neurology researchers at UC found that the rate of treatment with the standard therapy for acute ischemic stroke patients has doubled since 2005. Certified stroke centers, which have been at the forefront of research, public education and physician training, can surely take a bow for these improvements in America’s approach to stroke. * The pay-for-view editorial can be found at: http://www.neurology.org/content/76/23/1956.full.pdf+html
Brain Tumor Event Celebrates Good Wine and Good Cheer
Ronald Warnick, MD, with special guest Doc Rodgers at Thursday’s wine-tasting event. Photo by Dave Collins/UC Academic Health Center Communications Services. Some 240 friends of the UC Brain Tumor Center enjoyed food, friendship and fund-raising Thursday night at the second annual wine-tasting event at the CARE-Crawley Building on the UC Academic Health Center campus. Dozens of wines were sampled, and delicious food was served. Rich Seal, a member of the Brain Tumor Center’s Community Advisory Board, served as event chair. Ronald Warnick, MD, Medical Director of the Brain Tumor Center, announced that proceeds from the event are being earmarked for one or more educational kiosks, which will be placed at Brain Tumor Center treatment sites. Last year’s wine-tasting event funded a clinical trial that explored whether a two-drug treatment could help reduce the incidence of radiation necrosis (a lesion that usually occurs at the original tumor site) after radiosurgery in patients with metastatic brain cancer. Doc Rodgers, the 700WLW radio personality who has been treated at the UC Brain Tumor Center for metastatic brain tumors, gave an uplifting speech, punctuated by his trademark sense of humor. Doc, a non-smoker and former baseball pitcher who looks as if he could still throw a pretty mean fastball, had been suffering from undiagnosed lung cancer for some time when a headache that “felt like a nail in the middle of my head” forced him to the hospital and, ultimately, a diagnosis. Treatment for the metastasis and lung cancer began immediately. “My brain tumor may have saved my life,” he reflected. Doc closed his remarks by reading a message from a fortune cookie that he keeps with him: “Your cheerful outlook is one of your assets.” “I’ve held onto it,” Doc said. “It’s your attitude that matters. I’m going to continue holding onto this because truer words were never spoken.”